Basic Information
Provider Information | |||||||||
NPI: | 1508004979 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | CASA COLINA CENTERS FOR REHABILITATION, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | CASA COLINA HOME & COMMUNITY | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 255 E BONITA AVE | ||||||||
Address2: |   | ||||||||
City: | POMONA | ||||||||
State: | CA | ||||||||
PostalCode: | 917671923 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9095967733 | ||||||||
FaxNumber: | 9095937541 | ||||||||
Practice Location | |||||||||
Address1: | 255 E BONITA AVE | ||||||||
Address2: |   | ||||||||
City: | POMONA | ||||||||
State: | CA | ||||||||
PostalCode: | 917671923 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9095967733 | ||||||||
FaxNumber: | 9095937541 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/23/2009 | ||||||||
LastUpdateDate: | 01/23/2009 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | PEEK | ||||||||
AuthorizedOfficialFirstName: | RODNEY | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 9095967733 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | CASA COLINA CENTERS FOR REHABILITATION, INC. | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 320700000X | 191593695 | CA | Y |   | Residential Treatment Facilities | Residential Treatment Facility, Physical Disabilities |   |
No ID Information.