Healthcare Provider Details

I. General information

NPI: 1861859464
Provider Name (Legal Business Name): VETERANS ALCOHOL REHABILITATION PROGRAM, INC.- VARP, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/27/2016
Last Update Date: 10/12/2023
Certification Date: 10/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1103 N. 'D' ST.
SAN BERNADINO CA
92410-3524
US

IV. Provider business mailing address

1100 N. 'D' ST.
SAN BERNADINO CA
92410-3524
US

V. Phone/Fax

Practice location:
  • Phone: 909-381-3774
  • Fax: 909-381-6845
Mailing address:
  • Phone: 909-381-3774
  • Fax: 909-381-6845

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number360004FN
License Number StateCA

VIII. Authorized Official

Name: MRS. SHELLY MATTAZARO
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 909-381-3774