Basic Information
| Provider Information | |||||||||
| NPI: | 1215489000 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BOYS REPUBLIC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | BOYS REPUBLIC - POMONA RESIDENCE | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1907 BOYS REPUBLIC DR | ||||||||
| Address2: | |||||||||
| City: | CHINO HILLS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917095447 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9096281217 | ||||||||
| FaxNumber: | 9096279222 | ||||||||
| Practice Location | |||||||||
| Address1: | 733 N GAREY AVE | ||||||||
| Address2: | |||||||||
| City: | POMONA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 91767 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9096223556 | ||||||||
| FaxNumber: | 9093065427 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/27/2016 | ||||||||
| LastUpdateDate: | 04/25/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | TEO | ||||||||
| AuthorizedOfficialFirstName: | MARINA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | HEAD OF SERVICE | ||||||||
| AuthorizedOfficialTelephone: | 9096313075 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | BOYS REPUBLIC | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | LMFT | ||||||||
| NPICertificationDate: | 04/25/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | N | Agencies | Community/Behavioral Health | 320800000X | Y | Residential Treatment Facilities | Community Based Residential Treatment Facility, Mental Illness |
No ID Information.