Healthcare Provider Details

I. General information

NPI: 1376371187
Provider Name (Legal Business Name): HIS HOUSE NEW CREATION TREATMENT CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/23/2024
Last Update Date: 07/23/2024
Certification Date: 07/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

239 W 9TH ST
UPLAND CA
91786-5979
US

IV. Provider business mailing address

239 W 9TH ST
UPLAND CA
91786-5979
US

V. Phone/Fax

Practice location:
  • Phone: 909-981-6121
  • Fax: 909-912-8041
Mailing address:
  • Phone: 909-981-6121
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name: MS. LOUISA ESCARRZAGA GUTIERREZ
Title or Position: SUPPORT STAFF
Credential: RADT
Phone: 951-732-0437