Basic Information
| Provider Information | |||||||||
| NPI: | 1376995530 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | INSTITUTE FOR FAMILY CENTERED SERVICES INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CA MENTOR | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9166 ANAHEIM PL STE 200 | ||||||||
| Address2: | |||||||||
| City: | RANCHO CUCAMONGA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917308547 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9097367361 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 12631 IMPERIAL HWY | ||||||||
| Address2: | C103 | ||||||||
| City: | SANTA FE SPRINGS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 906704710 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9097367361 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/11/2016 | ||||||||
| LastUpdateDate: | 09/12/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| AuthorizedOfficialLastName: | RISOTTI | ||||||||
| AuthorizedOfficialFirstName: | STACEY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT OF OPERATIONS | ||||||||
| AuthorizedOfficialTelephone: | 5087406803 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | NATIONAL MENTOR HEALTHCARE, LLC | ||||||||
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| NPICertificationDate: | 09/12/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | CA | Y | Agencies | Community/Behavioral Health |
No ID Information.