Provider Demographics
NPI:1609978766
Name:SIMI VALLEY MTU
Entity Type:Organization
Organization Name:SIMI VALLEY MTU
Other - Org Name:GARDEN GROVE MTU
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LAURELL
Authorized Official - Middle Name:
Authorized Official - Last Name:MAURO
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:805-981-5223
Mailing Address - Street 1:2250 TRACY AVE
Mailing Address - Street 2:
Mailing Address - City:SIMI VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:93063-2753
Mailing Address - Country:US
Mailing Address - Phone:805-584-9501
Mailing Address - Fax:805-520-3571
Practice Address - Street 1:2250 TRACY AVE
Practice Address - Street 2:
Practice Address - City:SIMI VALLEY
Practice Address - State:CA
Practice Address - Zip Code:93063-2753
Practice Address - Country:US
Practice Address - Phone:805-584-9501
Practice Address - Fax:805-520-3571
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COUNTY OF VENTURA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-09-01
Last Update Date:2008-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACCS00018FOtherMEDICAL