Healthcare Provider Details

I. General information

NPI: 1457700411
Provider Name (Legal Business Name): BOYS REPUBLIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/09/2016
Last Update Date: 11/30/2022
Certification Date: 11/30/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1907 BOYS REPUBLIC DR
CHINO HILLS CA
91709
US

IV. Provider business mailing address

1907 BOYS REPUBLIC DR
CHINO HILLS CA
91709-5447
US

V. Phone/Fax

Practice location:
  • Phone: 909-628-1217
  • Fax: 909-306-5427
Mailing address:
  • Phone: 909-628-1217
  • Fax: 909-627-9222

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: FEDERICO ESCOBEDO JARQUE
Title or Position: CLINICAL DIRECTOR
Credential: LMFT, LPCC
Phone: 909-628-1217