Healthcare Provider Details

I. General information

NPI: 1659843118
Provider Name (Legal Business Name): CENTER FOR POSITIVE CHANGES STAY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/21/2018
Last Update Date: 01/15/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3482 SADDLE DR
SPRING VALLEY CA
91977-2035
US

IV. Provider business mailing address

9628 CAMPO RD STE M
SPRING VALLEY CA
91977-1233
US

V. Phone/Fax

Practice location:
  • Phone: 619-303-0812
  • Fax: 619-660-6604
Mailing address:
  • Phone: 619-660-3886
  • Fax: 619-660-6604

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: MS. DEANNA MELLOS
Title or Position: DIRECTOR
Credential:
Phone: 619-248-0552