Healthcare Provider Details

I. General information

NPI: 1053107268
Provider Name (Legal Business Name): DAMAREA HARRIS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/15/2025
Last Update Date: 04/15/2025
Certification Date: 04/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4825 GAVIOTA AVE
LONG BEACH CA
90807-1209
US

IV. Provider business mailing address

4825 GAVIOTA AVE
LONG BEACH CA
90807-1209
US

V. Phone/Fax

Practice location:
  • Phone: 213-809-1538
  • Fax:
Mailing address:
  • Phone: 213-809-1538
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3747P1801X
TaxonomyPersonal Care Attendant
License Number
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code374T00000X
TaxonomyReligious Nonmedical Nursing Personnel
License Number
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License Number
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code374K00000X
TaxonomyReligious Nonmedical Practitioner
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: