Healthcare Provider Details

I. General information

NPI: 1669905832
Provider Name (Legal Business Name): HAYNES FAMILY OF PROGRAMS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/05/2017
Last Update Date: 01/28/2020
Certification Date: 01/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

233 WEST BASELINE ROAD
LA VERNE CA
91750-2353
US

IV. Provider business mailing address

233 WEST BASELINE RD BOX 400
LA VERNE CA
91750-2353
US

V. Phone/Fax

Practice location:
  • Phone: 909-593-2581
  • Fax: 909-833-2998
Mailing address:
  • Phone: 909-593-2581
  • Fax: 909-614-7466

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: CASSANDRA JONES
Title or Position: STRTP ASSISTANT DIRECTOR
Credential:
Phone: 909-593-2581