MEDICARE: BOYS REPUBLIC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251S00000X	Community/Behavioral Health Agency
2	320800000X	Mental Illness Community Based Residential Treatment Facility

General Provider Information

NPI Number	:	1801346655
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BOYS REPUBLIC

Provider Business Mailing Address
First Line	:	1907 BOYS REPUBLIC DR
Second Line	:
City	:	CHINO HILLS
State	:	CA
Zip	:	91709-5447
Country	:	US
Telephone Number	:	909-628-1217
Fax Number	:	909-627-9222

Provider Business Practice Location Address
First Line	:	3850 EUCALYPTUS AVE
Second Line	:
City	:	CHINO HILLS
State	:	CA
Zip	:	91709-1807
Country	:	US
Telephone Number	:	909-597-9974
Fax Number	:	909-627-9222

Authorized Official
Title or Position	:	CLINICAL DIRECTOR
Name	:	FEDERICO ESCOBEDO JARQUE
Credential	:	LMFT, LPCC
Telephone Number	:	909-628-1217

Provider Enumeration Date	:	10/05/2016
Last Update Date	:	11/30/2022

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Directions to “BOYS REPUBLIC ” Practice Location

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