1477914679 NPI number — CHINO AVENUE CONGREGATE HOME INC

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 1477914679 NPI number — CHINO AVENUE CONGREGATE HOME INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CHINO AVENUE CONGREGATE HOME 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:
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:
1477914679
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/21/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 62
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BREA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92822-0062
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
714-747-6546
Provider Business Mailing Address Fax Number:
909-635-6476

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3408 CHINO AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHINO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91710-4714
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
909-270-3293
Provider Business Practice Location Address Fax Number:
909-635-6476
Provider Enumeration Date:
03/15/2016

Additional Information

Authorized Official

Authorized Official Last Name:
MARTINSON
Authorized Official First Name:
STEVEN
Authorized Official Middle Name:
Authorized Official Title or Position:
EXECUTIVE ASSISTANT
Authorized Official Telephone Number:
714-747-6546

Provider Taxonomy Codes

  • Taxonomy code: 314000000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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