1164548236 NPI number — HAYNES FAMILY OF PROGRAMS

Table of content: (NPI 1164548236)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164548236 NPI number — HAYNES FAMILY OF PROGRAMS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HAYNES FAMILY OF PROGRAMS
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:
LEROY HAYNES CENTER
Provider Other Organization Name Type Code:
5
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:
1164548236
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/12/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1350 3RD ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LA VERNE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91750-5201
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
909-593-2581
Provider Business Mailing Address Fax Number:
909-596-3567

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1350 3RD ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LA VERNE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91750-5201
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
909-593-2581
Provider Business Practice Location Address Fax Number:
909-596-3567
Provider Enumeration Date:
03/21/2007

Additional Information

Authorized Official

Authorized Official Last Name:
MAYDECK
Authorized Official First Name:
DANIEL
Authorized Official Middle Name:
S.
Authorized Official Title or Position:
CHIEF EXECUTIVE OFFICER
Authorized Official Telephone Number:
909-593-2581

Provider Taxonomy Codes

  • Taxonomy code: 103K00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 320800000X , with the licence number: 191501972 , 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)

  • Identifier: 7565A . This is a "OUTPATIENT MENTAL HEALTH" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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