Basic Information
| Provider Information | |||||||||
| NPI: | 1154788743 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | VETERANS ALCOHOLIC REHABILITATION PROGRAM, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | VARP, INC. | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1100 N D ST | ||||||||
| Address2: | |||||||||
| City: | SAN BERNARDINO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 924103524 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9093813774 | ||||||||
| FaxNumber: | 9093816845 | ||||||||
| Practice Location | |||||||||
| Address1: | 1139 N. 'D' ST. | ||||||||
| Address2: | |||||||||
| City: | SAN BERNARDINO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 924103524 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9093813774 | ||||||||
| FaxNumber: | 9093816845 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/27/2016 | ||||||||
| LastUpdateDate: | 01/27/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | JIMENEZ | ||||||||
| AuthorizedOfficialFirstName: | OSCAR | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 9093813774 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | VETERANS ALCOHOLIC REHABILITATION | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 324500000X | 360004FN | CA | Y | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility |
No ID Information.