Healthcare Provider Details

I. General information

NPI: 1093257545
Provider Name (Legal Business Name): CASA EDITHAFOUNDATION INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/15/2016
Last Update Date: 11/15/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1756 N HILL AVE
PASADENA CA
91104-1429
US

IV. Provider business mailing address

1756 N HILL AVE
PASADENA CA
91104-1429
US

V. Phone/Fax

Practice location:
  • Phone: 626-794-3916
  • Fax: 626-696-3929
Mailing address:
  • Phone: 626-794-3916
  • Fax: 626-696-3929

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number191222785
License Number StateCA

VIII. Authorized Official

Name: MRS. EDITH AVANZADO
Title or Position: EXECUTIVE DIRECTOR
Credential: R.D.
Phone: 626-374-7294