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General NPI Number Information
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NPI Number | 1104057496
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Entity Type | Organization
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Legal Business Name | MSJI HOME INC
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Dates
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Enumeration Date | 08/04/2009
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Last Update Date | 08/04/2009
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Provider Practice Location Address
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Address Line | 1324 JUANITA AV
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City | SANDIMAS
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State | CA
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Zip | 91773
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Country | US
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Telephone | 909-592-6003
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Fax | 909-592-3432
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Provider Business Mailing Address
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Address Line | P.O. BOX 4861
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City | SANDIMAS
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State | CA
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Zip | 91773
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Country | US
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Telephone | 909-592-6003
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Fax | 909-592-3432
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Authorized Official
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Title or Position | ADMINISTRATOR
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Name | MR. JAYDEV BHAVSAR
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Credential |
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Telephone | 909-592-6003
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 320900000X
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Taxonomy Name | Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
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License Number | 197801816
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License Number State | CA
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