Healthcare Provider Details

I. General information

NPI: 1083305411
Provider Name (Legal Business Name): BOYS REPUBLIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/17/2023
Last Update Date: 12/29/2023
Certification Date: 12/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3624 MARGARET FOWLER CT
CHINO HILLS CA
91709-5456
US

IV. Provider business mailing address

1907 BOYS REPUBLIC DR
CHINO HILLS CA
91709-5447
US

V. Phone/Fax

Practice location:
  • Phone: 909-740-3133
  • Fax: 909-306-5427
Mailing address:
  • Phone: 909-628-1217
  • Fax: 909-306-5427

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: JUDITH EDMUNDSON
Title or Position: CLINICAL SUPERVISOR/HEAD OF SERVICE
Credential: LPCC
Phone: 909-925-7693