Basic Information
Provider Information | |||||||||
NPI: | 1235553843 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | BENCHMARK YOUNG ADULT SCHOOL, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | BENCHMARK TRANSITIONS | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 25612 BARTON RD # 286 | ||||||||
Address2: |   | ||||||||
City: | LOMA LINDA | ||||||||
State: | CA | ||||||||
PostalCode: | 923543110 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9093073973 | ||||||||
FaxNumber: | 9097486424 | ||||||||
Practice Location | |||||||||
Address1: | 1906 ORANGE TREE LN STE 220 | ||||||||
Address2: |   | ||||||||
City: | REDLANDS | ||||||||
State: | CA | ||||||||
PostalCode: | 923744511 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8004744848 | ||||||||
FaxNumber: | 9097935090 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/18/2014 | ||||||||
LastUpdateDate: | 08/02/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | SKAGGS | ||||||||
AuthorizedOfficialFirstName: | SHELLEY | ||||||||
AuthorizedOfficialMiddleName: | R | ||||||||
AuthorizedOfficialTitleorPosition: | CHIEF MARKETING OFFICER | ||||||||
AuthorizedOfficialTelephone: | 9093514336 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 08/02/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0850X |   |   | N |   | Ambulatory Health Care Facilities | Clinic/Center | Adult Mental Health | 261QR0405X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Substance Use Disorder |
No ID Information.