Provider Demographics
NPI:1437039864
Name:EZRA MEDICAL REHAB & RECOVERY CENTER
Entity type:Organization
Organization Name:EZRA MEDICAL REHAB & RECOVERY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:TRISTAN
Authorized Official - Middle Name:
Authorized Official - Last Name:MIRELES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:347-348-0292
Mailing Address - Street 1:4438 PEBBLE BEACH DR
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95219
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4438 PEBBLE BEACH DR
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95219
Practice Address - Country:US
Practice Address - Phone:347-348-0292
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-09-05
Last Update Date:2025-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies