Healthcare Provider Details

I. General information

NPI: 1811383227
Provider Name (Legal Business Name): NEW ORIGINS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/13/2015
Last Update Date: 11/30/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 E REDLANDS BLVD STE 200
REDLANDS CA
92373-4775
US

IV. Provider business mailing address

PO BOX 3610
BLUE JAY CA
92317-3610
US

V. Phone/Fax

Practice location:
  • Phone: 909-233-5634
  • Fax:
Mailing address:
  • Phone: 909-233-5634
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number StateNULL

VIII. Authorized Official

Name: RONALD HONN
Title or Position: PROGRAM ADMINISTRATOR
Credential: CATC III
Phone: 909-233-5634