=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194585547
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BENCHMARK YOUNG ADULT SCHOOL, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/21/2024
-----------------------------------------------------
Last Update Date | 03/21/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10132 CAMULOS AVE
-----------------------------------------------------
City | MONTCLAIR
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91763-3608
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-686-6056
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1910 ORANGE TREE LN STE 300
-----------------------------------------------------
City | REDLANDS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92374-4500
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PARTNER
-----------------------------------------------------
Name | DR. THOMAS MCNULTY
-----------------------------------------------------
Credential | PHARMD
-----------------------------------------------------
Telephone | 818-209-5011
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 323P00000X
-----------------------------------------------------
Taxonomy Name | Psychiatric Residential Treatment Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------