Healthcare Provider Details

I. General information

NPI: 1205316882
Provider Name (Legal Business Name): TARELL D HONORE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/14/2018
Last Update Date: 08/14/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17070 WALNUT VILLAGE PKWY STE K
FONTANA CA
92336-3285
US

IV. Provider business mailing address

PO BOX 894
DESERT HOT SPRINGS CA
92240-0894
US

V. Phone/Fax

Practice location:
  • Phone: 909-320-8300
  • Fax:
Mailing address:
  • Phone: 951-355-8826
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3104A0630X
TaxonomyAssisted Living Facility (Behavioral Disturbances)
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: