=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770003766
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HARBOR VILLAGE DETOXIFICATION AND REHABILITATION INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/21/2017
-----------------------------------------------------
Last Update Date | 06/21/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1620 EL TRAVESIA DR
-----------------------------------------------------
City | LA HABRA HEIGHTS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90631-8002
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-904-7003
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5787 LITTLE SHAY DR
-----------------------------------------------------
City | FONTANA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92336-4593
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-904-7003
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR / LICENSE MANAGER
-----------------------------------------------------
Name | MS. MARIA CATHERINE KOH CHUA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 909-904-7003
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QR0405X
-----------------------------------------------------
Taxonomy Name | Substance Use Disorder Rehabilitation Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------