=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154590495
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | OUR LADY OF MERCY HOME
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/20/2008
-----------------------------------------------------
Last Update Date | 02/20/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3409 E HILLTONIA DR
-----------------------------------------------------
City | WEST COVINA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91792-2934
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-444-5796
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1862
-----------------------------------------------------
City | WALNUT
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91788-1862
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-444-5796
-----------------------------------------------------
Fax | 909-444-5796
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | LYDIA SEBASTIAN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 909-444-5796
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 320600000X
-----------------------------------------------------
Taxonomy Name | Intellectual and/or Developmental Disabilities Residential Treatment Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------