Healthcare Provider Details

I. General information

NPI: 1174219000
Provider Name (Legal Business Name): READY TO EVOLVE RECOVERY CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/13/2023
Last Update Date: 11/01/2024
Certification Date: 11/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9320 BASE LINE RD STE A
RANCHO CUCAMONGA CA
91701-5829
US

IV. Provider business mailing address

9320 BASE LINE RD STE A
RANCHO CUCAMONGA CA
91701-5829
US

V. Phone/Fax

Practice location:
  • Phone: 909-746-7952
  • Fax: 909-360-1332
Mailing address:
  • Phone: 909-746-7952
  • Fax: 909-360-1332

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: KELLINA SANDERS
Title or Position: PROGRAM DIRECTOR
Credential:
Phone: 909-746-7952