Healthcare Provider Details

I. General information

NPI: 1932013588
Provider Name (Legal Business Name): MADISON LEEANNE TAVIS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/30/2026
Last Update Date: 09/30/2026
Certification Date: 09/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1221 W 3RD ST
LOS ANGELES CA
90017-5181
US

IV. Provider business mailing address

2159 15TH INFANTRY AVE
SEASIDE CA
93955-8309
US

V. Phone/Fax

Practice location:
  • Phone: 818-470-4584
  • Fax:
Mailing address:
  • Phone: 831-718-7614
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: