Healthcare Provider Details

I. General information

NPI: 1467713743
Provider Name (Legal Business Name): LEROY HAYNES CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/04/2012
Last Update Date: 06/04/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

233 BASELINE RD
LA VERNE CA
91750-2353
US

IV. Provider business mailing address

233 BASELINE RD
LA VERNE CA
91750-2353
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License NumberPT 34218
License Number StateCA

VIII. Authorized Official

Name: JENNIFER MOSSON
Title or Position: LICENSED PSYCHIATRIC TECHNICIAN
Credential:
Phone: 909-592-3281