=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124123211
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PERRIS VALLEY RECOVERY PROGRAM, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/13/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 236 E 3RD ST SUITE B
-----------------------------------------------------
City | PERRIS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92570-2223
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 951-657-2960
-----------------------------------------------------
Fax | 951-940-4600
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 236 E 3RD ST SUITE B
-----------------------------------------------------
City | PERRIS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92570-2223
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 951-657-2960
-----------------------------------------------------
Fax | 951-940-4600
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT/CEO
-----------------------------------------------------
Name | TINYA K HOLT
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 951-657-2960
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251B00000X
-----------------------------------------------------
Taxonomy Name | Case Management Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------