Basic Information
| Provider Information | |||||||||
| NPI: | 1952749525 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HEARTS & LIVES | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 4644 | ||||||||
| Address2: | |||||||||
| City: | BLUE JAY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923174644 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9093383222 | ||||||||
| FaxNumber: | 9093383221 | ||||||||
| Practice Location | |||||||||
| Address1: | 24028 LAKE DR | ||||||||
| Address2: | |||||||||
| City: | CRESTLINE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92325 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9093383222 | ||||||||
| FaxNumber: | 9093383222 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/05/2013 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | RODRIGUEZ | ||||||||
| AuthorizedOfficialFirstName: | LUVIA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 9093383222 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | Y | Agencies | Community/Behavioral Health |
No ID Information.