Healthcare Provider Details

I. General information

NPI: 1356975148
Provider Name (Legal Business Name): ETTIE LEE HOMES, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/02/2020
Last Update Date: 10/23/2024
Certification Date: 10/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11282 SPRUCE AVE
BLOOMINGTON CA
92316-3228
US

IV. Provider business mailing address

160 E HOLT AVE STE B
POMONA CA
91767-5407
US

V. Phone/Fax

Practice location:
  • Phone: 909-877-3330
  • Fax: 909-355-6678
Mailing address:
  • Phone: 909-620-2521
  • Fax: 909-620-9793

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: WINDY LUNA PEREZ
Title or Position: QA MANAGER
Credential:
Phone: 909-620-2521