Provider Demographics
NPI:1124123211
Name:PERRIS VALLEY RECOVERY PROGRAM, INC.
Entity type:Organization
Organization Name:PERRIS VALLEY RECOVERY PROGRAM, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:
Authorized Official - First Name:TINYA
Authorized Official - Middle Name:K
Authorized Official - Last Name:HOLT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:951-657-2960
Mailing Address - Street 1:236 E 3RD ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:PERRIS
Mailing Address - State:CA
Mailing Address - Zip Code:92570-2223
Mailing Address - Country:US
Mailing Address - Phone:951-657-2960
Mailing Address - Fax:951-940-4600
Practice Address - Street 1:236 E 3RD ST
Practice Address - Street 2:SUITE B
Practice Address - City:PERRIS
Practice Address - State:CA
Practice Address - Zip Code:92570-2223
Practice Address - Country:US
Practice Address - Phone:951-657-2960
Practice Address - Fax:951-940-4600
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA3312Medicaid