Provider Demographics
NPI:1770003766
Name:HARBOR VILLAGE DETOXIFICATION AND REHABILITATION INC.
Entity Type:Organization
Organization Name:HARBOR VILLAGE DETOXIFICATION AND REHABILITATION INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR / LICENSE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:MARIA CATHERINE
Authorized Official - Middle Name:KOH
Authorized Official - Last Name:CHUA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-904-7003
Mailing Address - Street 1:5787 LITTLE SHAY DR
Mailing Address - Street 2:
Mailing Address - City:FONTANA
Mailing Address - State:CA
Mailing Address - Zip Code:92336-4593
Mailing Address - Country:US
Mailing Address - Phone:909-904-7003
Mailing Address - Fax:
Practice Address - Street 1:1620 EL TRAVESIA DR
Practice Address - Street 2:
Practice Address - City:LA HABRA HEIGHTS
Practice Address - State:CA
Practice Address - Zip Code:90631-8002
Practice Address - Country:US
Practice Address - Phone:909-904-7003
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-21
Last Update Date:2017-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAC4033816OtherCALIFORNIA SECRETARY OF STATE REGISTRATION