Basic Information
| Provider Information | |||||||||
| NPI: | 1902436744 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | KOINONIA FOSTER HOMES, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1403 | ||||||||
| Address2: | |||||||||
| City: | LOOMIS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 956501403 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9166525802 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1881 BUSINESS CENTER DR STE 10 | ||||||||
| Address2: | |||||||||
| City: | SAN BERNARDINO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 924083465 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9098902381 | ||||||||
| FaxNumber: | 9098900580 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/21/2020 | ||||||||
| LastUpdateDate: | 01/21/2020 | ||||||||
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| AuthorizedOfficialLastName: | SICKLER | ||||||||
| AuthorizedOfficialFirstName: | TIFFANY | ||||||||
| AuthorizedOfficialMiddleName: | DANIELLE | ||||||||
| AuthorizedOfficialTitleorPosition: | PROGRAM DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 3109263916 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | KOINONIA FOSTER HOMES, INC. | ||||||||
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| AuthorizedOfficialCredential: | PHD | ||||||||
| NPICertificationDate: | 01/21/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | N | Agencies | Community/Behavioral Health | 253J00000X | Y | Agencies | Foster Care Agency |
No ID Information.