1356975148 NPI number — ETTIE LEE HOMES, INC

Table of content: (NPI 1356975148)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356975148 NPI number — ETTIE LEE HOMES, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ETTIE LEE HOMES, INC
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:
ETTIE LEE YOUTH AND FAMILY SERVICES
Provider Other Organization Name Type Code:
3
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:
1356975148
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/20/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
160 E HOLT AVE STE B
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
POMONA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91767-5407
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
909-620-2521
Provider Business Mailing Address Fax Number:
909-620-9793

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11282 SPRUCE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BLOOMINGTON
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92316-3228
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
909-877-3330
Provider Business Practice Location Address Fax Number:
909-355-6678
Provider Enumeration Date:
03/02/2020

Additional Information

Authorized Official

Authorized Official Last Name:
JARVIE
Authorized Official First Name:
KELLIE
Authorized Official Middle Name:
MARIE
Authorized Official Title or Position:
DIRECTOR OF RESIDENTIAL TREATMENT
Authorized Official Telephone Number:
626-383-5334

Provider Taxonomy Codes

  • Taxonomy code: 322D00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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