Healthcare Provider Details

I. General information

NPI: 1972862043
Provider Name (Legal Business Name): TAVARUA MEDICAL REHABILITATION SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/10/2012
Last Update Date: 05/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21505 NORWALK BLVD
HAWAIIAN GARDENS CA
90716-1121
US

IV. Provider business mailing address

26460 SUMMIT CIR
SANTA CLARITA CA
91350-2991
US

V. Phone/Fax

Practice location:
  • Phone: 562-916-7581
  • Fax: 562-916-7592
Mailing address:
  • Phone: 661-254-6630
  • Fax: 661-254-6644

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number960000644
License Number StateCA

VIII. Authorized Official

Name: STAN SHARMA
Title or Position: EXECUTIVE DIRECTOR
Credential: PHD
Phone: 661-254-6630