Provider Demographics
NPI:1598554396
Name:MAA TARA LLC
Entity type:Organization
Organization Name:MAA TARA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR/CEO
Authorized Official - Prefix:
Authorized Official - First Name:KAMILLA
Authorized Official - Middle Name:
Authorized Official - Last Name:ARCHUNDIA
Authorized Official - Suffix:
Authorized Official - Credentials:CPT
Authorized Official - Phone:951-472-8077
Mailing Address - Street 1:200 E ROWLAND ST UNIT 2104
Mailing Address - Street 2:
Mailing Address - City:COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91723-3146
Mailing Address - Country:US
Mailing Address - Phone:951-472-8077
Mailing Address - Fax:
Practice Address - Street 1:4469 N BROADMOOR AVE
Practice Address - Street 2:
Practice Address - City:COVINA
Practice Address - State:CA
Practice Address - Zip Code:91722-2201
Practice Address - Country:US
Practice Address - Phone:951-472-8077
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-05-06
Last Update Date:2025-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251E00000XAgenciesHome Health
No246RP1900XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyPhlebotomyGroup - Multi-Specialty
No246QL0900XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, PathologyLaboratory ManagementGroup - Multi-Specialty