Healthcare Provider Details

I. General information

NPI: 1578893699
Provider Name (Legal Business Name): GROUP HOME SUPPORT SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/12/2010
Last Update Date: 05/25/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

245 NORTH MURRAY STREET
BANNING CA
92220-5528
US

IV. Provider business mailing address

245 NORTH MURRAY STREET
BANNING CA
92220-5528
US

V. Phone/Fax

Practice location:
  • Phone: 951-849-8812
  • Fax: 951-755-8915
Mailing address:
  • Phone: 951-849-8812
  • Fax: 951-755-8915

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number261QMO801X
License Number StateCA

VIII. Authorized Official

Name: MRS. SHARON HEASTON
Title or Position: EXECUTIVE DIRECTOR
Credential: MFT
Phone: 909-224-3942