Basic Information
| Provider Information | |||||||||
| NPI: | 1992890057 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ETTIE LEE HOMES, INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ETTIE LEE HOMES POMONA | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5146 MAINE AVE, P.O. BOX 339 | ||||||||
| Address2: | |||||||||
| City: | BALDWIN PARK | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917060339 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6269604861 | ||||||||
| FaxNumber: | 6269606241 | ||||||||
| Practice Location | |||||||||
| Address1: | 160 E HOLT AVE STE B | ||||||||
| Address2: | |||||||||
| City: | POMONA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917675407 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9096202521 | ||||||||
| FaxNumber: | 9096209793 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/04/2006 | ||||||||
| LastUpdateDate: | 09/15/2022 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | JARVIE | ||||||||
| AuthorizedOfficialFirstName: | KELLIE | ||||||||
| AuthorizedOfficialMiddleName: | MARIE | ||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT OF OPERATIONS | ||||||||
| AuthorizedOfficialTelephone: | 6263835334 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 09/15/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 322D00000X | C07933 | CA | Y | Residential Treatment Facilities | Residential Treatment Facility, Emotionally Disturbed Children |
ID Information
| ID | Type | State | Issuer | Description | 7008 | 01 | CA | DRUG & ALCOHOL | OTHER | 7453A | 01 | CA | MENTAL HEALTH | OTHER | 7712A | 01 | CA | MENTAL HEALTH | OTHER |