Healthcare Provider Details

I. General information

NPI: 1023560836
Provider Name (Legal Business Name): BOYS REPUBLIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/27/2016
Last Update Date: 12/29/2023
Certification Date: 12/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

802 OCEAN VIEW AVE
MONROVIA CA
91016-2420
US

IV. Provider business mailing address

1907 BOYS REPUBLIC DR
CHINO HILLS CA
91709-5447
US

V. Phone/Fax

Practice location:
  • Phone: 909-628-1217
  • Fax:
Mailing address:
  • Phone: 909-628-1217
  • Fax: 909-627-9222

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: WHITNEY PAINE
Title or Position: CLINICIAN/HEAD OF SERVICE
Credential: LCSW
Phone: 909-993-2658