Basic Information
| Provider Information | |||||||||
| NPI: | 1275167066 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ETTIE LEE HOMES, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 160 E HOLT AVE STE B | ||||||||
| Address2: | |||||||||
| City: | POMONA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917675407 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9096202521 | ||||||||
| FaxNumber: | 9096209793 | ||||||||
| Practice Location | |||||||||
| Address1: | 7637 CITRUS AVE | ||||||||
| Address2: | |||||||||
| City: | FONTANA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923361911 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9098235662 | ||||||||
| FaxNumber: | 9093556678 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/02/2020 | ||||||||
| LastUpdateDate: | 03/02/2020 | ||||||||
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| AuthorizedOfficialLastName: | JARVIE | ||||||||
| AuthorizedOfficialFirstName: | KELLIE | ||||||||
| AuthorizedOfficialMiddleName: | MARIE | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF RESIDENTIAL TREATMENT | ||||||||
| AuthorizedOfficialTelephone: | 6263835334 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 03/02/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 322D00000X | Y | Residential Treatment Facilities | Residential Treatment Facility, Emotionally Disturbed Children |
No ID Information.