Provider Demographics
NPI:1215102215
Name:AIVA HEALTH SERVICES
Entity type:Organization
Organization Name:AIVA HEALTH SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:TAVONIA
Authorized Official - Middle Name:SIDONEY
Authorized Official - Last Name:RUSSELL
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:310-462-6082
Mailing Address - Street 1:17810 ELM CT
Mailing Address - Street 2:
Mailing Address - City:CARSON
Mailing Address - State:CA
Mailing Address - Zip Code:90746-7429
Mailing Address - Country:US
Mailing Address - Phone:310-462-6082
Mailing Address - Fax:310-638-3549
Practice Address - Street 1:8453 S VAN NESS AVE
Practice Address - Street 2:
Practice Address - City:INGLEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90305-1519
Practice Address - Country:US
Practice Address - Phone:323-778-1177
Practice Address - Fax:323-778-2477
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-30
Last Update Date:2009-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAFNP 38172261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center