Healthcare Provider Details

I. General information

NPI: 1518552165
Provider Name (Legal Business Name): LIZZBETH TAVARES RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/05/2021
Last Update Date: 03/05/2021
Certification Date: 03/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1463 S 4TH ST
EL CENTRO CA
92243-4749
US

IV. Provider business mailing address

1561 I ST APT 5
BRAWLEY CA
92227-3639
US

V. Phone/Fax

Practice location:
  • Phone: 760-594-9100
  • Fax:
Mailing address:
  • Phone: 760-604-9139
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number95200863
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: