Healthcare Provider Details

I. General information

NPI: 1760552111
Provider Name (Legal Business Name): LAXFORD HOUSE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/09/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16814 E LAXFORD RD
AZUSA CA
91702-5222
US

IV. Provider business mailing address

16814 E LAXFORD RD
AZUSA CA
91702-5222
US

V. Phone/Fax

Practice location:
  • Phone: 626-969-0800
  • Fax: 626-969-0800
Mailing address:
  • Phone: 626-969-0800
  • Fax: 626-969-0800

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License Number
License Number StateCA

VIII. Authorized Official

Name: JULIET L HEBREO
Title or Position: ADMINISTRATOR
Credential:
Phone: 626-826-7870