Healthcare Provider Details

I. General information

NPI: 1336426717
Provider Name (Legal Business Name): PASA ALTA MANOR
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/14/2011
Last Update Date: 11/14/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1790 N FAIR OAKS AVE
PASADENA CA
91103-1617
US

IV. Provider business mailing address

PO BOX 93577
PASADENA CA
91109-3577
US

V. Phone/Fax

Practice location:
  • Phone: 626-798-6986
  • Fax: 626-798-5970
Mailing address:
  • Phone: 626-798-6986
  • Fax: 626-798-5970

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number191204078
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number191222713
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number197600074
License Number StateCA

VIII. Authorized Official

Name: DEWALT BROWN
Title or Position: CEO
Credential: MBA
Phone: 626-926-3519