1053730937 NPI number — NEW CREATION BEHAVIORAL HEALTHCARE FOUNDATION

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053730937 NPI number — NEW CREATION BEHAVIORAL HEALTHCARE FOUNDATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NEW CREATION BEHAVIORAL HEALTHCARE FOUNDATION
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1053730937
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/08/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
333 E ARROW HWY UNIT 220
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
UPLAND
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91785-7008
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
909-519-0767
Provider Business Mailing Address Fax Number:
909-985-2316

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2511 S MCCARTY DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COLTON
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92324-9220
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
909-519-0767
Provider Business Practice Location Address Fax Number:
909-985-2316
Provider Enumeration Date:
04/08/2014

Additional Information

Authorized Official

Authorized Official Last Name:
SWANSON
Authorized Official First Name:
GLENN
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO/DIRECTOR
Authorized Official Telephone Number:
909-519-0767

Provider Taxonomy Codes

  • Taxonomy code: 324500000X , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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