Basic Information
| Provider Information | |||||||||
| NPI: | 1528641511 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | EAST VALLEY CHARLEE, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| OtherOrganizationName: | SANTA MARIA GROUP HOME | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 440 CAJON ST | ||||||||
| Address2: | |||||||||
| City: | REDLANDS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923735955 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9093075777 | ||||||||
| FaxNumber: | 9093075776 | ||||||||
| Practice Location | |||||||||
| Address1: | 35895 SANTA MARIA ST | ||||||||
| Address2: | |||||||||
| City: | YUCAIPA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923995504 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9093075777 | ||||||||
| FaxNumber: | 9093075776 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/28/2021 | ||||||||
| LastUpdateDate: | 09/20/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CHALI | ||||||||
| AuthorizedOfficialFirstName: | RICKY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | FACILITATOR | ||||||||
| AuthorizedOfficialTelephone: | 9093075777 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | EAST VALLEY CHARLEE, INC. | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 09/20/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 322D00000X | Y | Residential Treatment Facilities | Residential Treatment Facility, Emotionally Disturbed Children |
No ID Information.