Provider Demographics
NPI:1467948018
Name:TAVAKOLI, ANITA
Entity Type:Individual
Prefix:MRS
First Name:ANITA
Middle Name:
Last Name:TAVAKOLI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:129 CALDERON
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92618-1058
Mailing Address - Country:US
Mailing Address - Phone:703-395-1649
Mailing Address - Fax:
Practice Address - Street 1:8 WHATNEY UNIT 100
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92618-2879
Practice Address - Country:US
Practice Address - Phone:703-395-1649
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-06
Last Update Date:2018-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X, 251B00000X
CA376G00000X, 253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No251B00000XAgenciesCase Management
No376G00000XNursing Service Related ProvidersNursing Home Administrator