Provider Demographics
NPI:1184990814
Name:TAVARUA MEDICAL REHABILITATION SERVICES
Entity type:Organization
Organization Name:TAVARUA MEDICAL REHABILITATION SERVICES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:CYNTHIA
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:BLANKS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:661-254-6630
Mailing Address - Street 1:26460 SUMMIT CIR
Mailing Address - Street 2:
Mailing Address - City:SANTA CLARITA
Mailing Address - State:CA
Mailing Address - Zip Code:91350-2991
Mailing Address - Country:US
Mailing Address - Phone:661-254-6630
Mailing Address - Fax:661-254-6644
Practice Address - Street 1:474 S CITRUS AVE
Practice Address - Street 2:
Practice Address - City:AZUSA
Practice Address - State:CA
Practice Address - Zip Code:91702-4733
Practice Address - Country:US
Practice Address - Phone:626-858-9500
Practice Address - Fax:626-858-9090
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-27
Last Update Date:2023-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QM2800X
CA19-126261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
No261QM2800XAmbulatory Health Care FacilitiesClinic/CenterMethadone
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA19CQMedicaid
CA19-126OtherSTATE NTP LICENSE