Healthcare Provider Details

I. General information

NPI: 1891167912
Provider Name (Legal Business Name): HABILITATIVE HOMES RESIDENTIAL CARE FACILITY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/28/2015
Last Update Date: 03/16/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11775 WALNUT RD
LAKESIDE CA
92040-5624
US

IV. Provider business mailing address

11775 WALNUT ROAD
LAKESIDE CA
92040
US

V. Phone/Fax

Practice location:
  • Phone: 619-270-4484
  • Fax:
Mailing address:
  • Phone: 619-270-4484
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number374603669
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code3104A0630X
TaxonomyAssisted Living Facility (Behavioral Disturbances)
License Number374603669
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License Number374603669
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number374603669
License Number StateCA

VIII. Authorized Official

Name: DAVID CLARENCE LARSON
Title or Position: LICENEE/OWNER/ADMINISTRATOR
Credential:
Phone: 619-456-3742