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General NPI Number Information
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NPI Number | 1598554396
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Entity Type | Organization
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Legal Business Name | MAA TARA LLC
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Dates
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Enumeration Date | 05/06/2025
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Last Update Date | 05/06/2025
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Provider Practice Location Address
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Address Line | 4469 N BROADMOOR AVE
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City | COVINA
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State | CA
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Zip | 91722-2201
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Country | US
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Telephone | 951-472-8077
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Fax |
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Provider Business Mailing Address
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Address Line | 200 E ROWLAND ST UNIT 2104
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City | COVINA
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State | CA
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Zip | 91723-3146
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Country | US
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Telephone | 951-472-8077
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Fax |
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Authorized Official
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Title or Position | DIRECTOR/CEO
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Name | KAMILLA ARCHUNDIA
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Credential | CPT
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Telephone | 951-472-8077
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 246RP1900X
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Taxonomy Name | Phlebotomy Technician
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 246QL0900X
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Taxonomy Name | Laboratory Management Specialist/Technologist
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 251E00000X
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Taxonomy Name | Home Health Agency
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License Number |
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License Number State |
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