Healthcare Provider Details

I. General information

NPI: 1598554396
Provider Name (Legal Business Name): MAA TARA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/06/2025
Last Update Date: 05/06/2025
Certification Date: 05/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4469 N BROADMOOR AVE
COVINA CA
91722-2201
US

IV. Provider business mailing address

200 E ROWLAND ST UNIT 2104
COVINA CA
91723-3146
US

V. Phone/Fax

Practice location:
  • Phone: 951-472-8077
  • Fax:
Mailing address:
  • Phone: 951-472-8077
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code246QL0900X
TaxonomyLaboratory Management Specialist/Technologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code246RP1900X
TaxonomyPhlebotomy Technician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State

VIII. Authorized Official

Name: KAMILLA ARCHUNDIA
Title or Position: DIRECTOR/CEO
Credential: CPT
Phone: 951-472-8077