Healthcare Provider Details

I. General information

NPI: 1164548236
Provider Name (Legal Business Name): HAYNES FAMILY OF PROGRAMS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/21/2007
Last Update Date: 04/12/2021
Certification Date: 04/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1350 3RD ST
LA VERNE CA
91750-5201
US

IV. Provider business mailing address

1350 3RD ST
LA VERNE CA
91750-5201
US

V. Phone/Fax

Practice location:
  • Phone: 909-593-2581
  • Fax: 909-596-3567
Mailing address:
  • Phone: 909-593-2581
  • Fax: 909-596-3567

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number191501972
License Number StateCA

VIII. Authorized Official

Name: MR. DANIEL S. MAYDECK
Title or Position: CHIEF EXECUTIVE OFFICER
Credential:
Phone: 909-593-2581