Healthcare Provider Details

I. General information

NPI: 1629803804
Provider Name (Legal Business Name): ANGELES ESPECIALES PARENT SUPPORT GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/05/2024
Last Update Date: 09/05/2024
Certification Date: 09/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17644 VINE CT
FONTANA CA
92335-3768
US

IV. Provider business mailing address

17644 VINE CT
FONTANA CA
92335-3768
US

V. Phone/Fax

Practice location:
  • Phone: 909-699-3614
  • Fax:
Mailing address:
  • Phone: 909-699-3614
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251V00000X
TaxonomyVoluntary or Charitable Agency
License Number
License Number State

VIII. Authorized Official

Name: HELEN NERI
Title or Position: DIRECTOR
Credential: CEO
Phone: 909-699-3614