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General NPI Number Information
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NPI Number | 1255579215
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Entity Type | Organization
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Legal Business Name | HACIENDA VILLAGE
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Dates
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Enumeration Date | 01/29/2009
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Last Update Date | 01/29/2009
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Provider Practice Location Address
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Address Line | 1435 UNIVERSITY AVE
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City | RIVERSIDE
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State | CA
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Zip | 92507-4466
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Country | US
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Telephone | 951-683-4056
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Fax | 951-788-5352
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Provider Business Mailing Address
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Address Line | 1435 UNIVERSITY AVE
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City | RIVERSIDE
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State | CA
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Zip | 92507-4466
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Country | US
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Telephone | 951-683-4056
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Fax | 951-788-5352
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Authorized Official
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Title or Position | CHIEF EXECUTIVE OFFICER
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Name | SHAWN S SHIRAZI
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Credential |
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Telephone | 951-683-4056
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0850X
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Taxonomy Name | Adult Mental Health Clinic/Center
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License Number | 336411358
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License Number State | CA
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