Healthcare Provider Details

I. General information

NPI: 1568094084
Provider Name (Legal Business Name): MILESTONE HOUSE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/12/2020
Last Update Date: 10/05/2023
Certification Date: 09/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1816 PORTOFINO DR
OCEANSIDE CA
92054-6130
US

IV. Provider business mailing address

1816 PORTOFINO DR
OCEANSIDE CA
92054-6130
US

V. Phone/Fax

Practice location:
  • Phone: 760-433-6361
  • Fax: 760-439-7402
Mailing address:
  • Phone: 760-433-6361
  • Fax: 760-439-7402

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: BEVERLY BOONE
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 760-433-6361