Healthcare Provider Details

I. General information

NPI: 1255579215
Provider Name (Legal Business Name): HACIENDA VILLAGE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/29/2009
Last Update Date: 01/29/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1435 UNIVERSITY AVE
RIVERSIDE CA
92507-4466
US

IV. Provider business mailing address

1435 UNIVERSITY AVE
RIVERSIDE CA
92507-4466
US

V. Phone/Fax

Practice location:
  • Phone: 951-683-4056
  • Fax: 951-788-5352
Mailing address:
  • Phone: 951-683-4056
  • Fax: 951-788-5352

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number336411358
License Number StateCA

VIII. Authorized Official

Name: SHAWN S SHIRAZI
Title or Position: CHIEF EXECUTIVE OFFICER
Credential:
Phone: 951-683-4056