Healthcare Provider Details

I. General information

NPI: 1801057187
Provider Name (Legal Business Name): MR. DOUGLAS HORACIO TAVIRA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/19/2008
Last Update Date: 11/19/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3801 UNIVERSITY AVE SUITE 400
RIVERSIDE CA
92501-3247
US

IV. Provider business mailing address

4556 CENTRAL AVE
RIVERSIDE CA
92506-2327
US

V. Phone/Fax

Practice location:
  • Phone: 951-955-7334
  • Fax:
Mailing address:
  • Phone: 951-367-7185
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: