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General NPI Number Information
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NPI Number | 1073703898
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Entity Type | Organization
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Legal Business Name | BRANDON J INC/SERENITY PLACE
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Dates
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Enumeration Date | 07/27/2007
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Last Update Date | 07/27/2007
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Provider Practice Location Address
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Address Line | 128 E. G ST STE #111
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City | COLTON
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State | CA
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Zip | 92324
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Country | US
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Telephone | 909-433-0330
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Fax | 909-433-0399
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Provider Business Mailing Address
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Address Line | 128 E G ST STE 111 140 W. D ST
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City | COLTON
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State | CA
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Zip | 92324-2943
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Country | US
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Telephone | 909-433-0330
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Fax | 909-433-0399
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | MRS. LOURDES A LEFEVRE
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Credential |
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Telephone | 909-433-0330
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 3245S0500X
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Taxonomy Name | Children's Substance Abuse Rehabilitation Facility
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License Number | 368607
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License Number State | CA
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