Basic Information
| Provider Information | |||||||||
| NPI: | 1255879417 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DAVID AND MARGARET HOME, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | DAVID AND MARGARET STRTP | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1350 3RD ST | ||||||||
| Address2: | |||||||||
| City: | LA VERNE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917505201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9095965921 | ||||||||
| FaxNumber: | 9095967583 | ||||||||
| Practice Location | |||||||||
| Address1: | 1350 3RD ST | ||||||||
| Address2: | |||||||||
| City: | LA VERNE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917505201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9095965921 | ||||||||
| FaxNumber: | 9095967583 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/08/2017 | ||||||||
| LastUpdateDate: | 02/16/2017 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | RICH | ||||||||
| AuthorizedOfficialFirstName: | CHARLES | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 9095965921 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | DAVID AND MARGARET HOME, INC. | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | LCSW | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 322D00000X | 191500192 | CA | Y | Residential Treatment Facilities | Residential Treatment Facility, Emotionally Disturbed Children |
ID Information
| ID | Type | State | Issuer | Description | 01227 | 05 | CA | MEDICAID |