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General NPI Number Information
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NPI Number | 1336426717
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Entity Type | Organization
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Legal Business Name | PASA ALTA MANOR
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Dates
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Enumeration Date | 11/14/2011
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Last Update Date | 11/14/2011
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Provider Practice Location Address
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Address Line | 1790 N FAIR OAKS AVE
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City | PASADENA
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State | CA
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Zip | 91103-1617
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Country | US
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Telephone | 626-798-6986
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Fax | 626-798-5970
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Provider Business Mailing Address
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Address Line | PO BOX 93577
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City | PASADENA
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State | CA
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Zip | 91109-3577
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Country | US
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Telephone | 626-798-6986
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Fax | 626-798-5970
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Authorized Official
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Title or Position | CEO
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Name | DEWALT BROWN
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Credential | MBA
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Telephone | 626-926-3519
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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 | 191222713
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License Number State | CA
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Taxonomy #2
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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 | 197600074
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License Number State | CA
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Taxonomy #3
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Taxonomy Code | 320800000X
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Taxonomy Name | Mental Illness Community Based Residential Treatment Facility
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License Number | 191204078
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License Number State | CA
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