Healthcare Provider Details

I. General information

NPI: 1437451259
Provider Name (Legal Business Name): HI-LAND MOUNTAIN HOMES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/30/2010
Last Update Date: 11/30/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

27482 N. BAY ROAD.
LAKE ARROWHEAD CA
92352
US

IV. Provider business mailing address

PO BOX 1502
LAKE ARROWHEAD CA
92352-1502
US

V. Phone/Fax

Practice location:
  • Phone: 909-338-1234
  • Fax:
Mailing address:
  • Phone: 909-338-1234
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number360082AP
License Number StateCA

VIII. Authorized Official

Name: KORY AVARELL
Title or Position: CEO
Credential:
Phone: 909-338-1234