=====================================================
General NPI Number Information
=====================================================
NPI Number | 1346691235
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | INLAND EMPIRE RESIDENTIAL CENTERS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/22/2016
-----------------------------------------------------
Last Update Date | 06/22/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 710 CHURCH ST
-----------------------------------------------------
City | REDLANDS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92374-3538
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-798-0823
-----------------------------------------------------
Fax | 909-798-8071
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 710 CHURCH ST
-----------------------------------------------------
City | REDLANDS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92374-3538
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-798-0823
-----------------------------------------------------
Fax | 909-798-8071
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | MRS. TANYA ANN RIGOT
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 909-798-0823
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 322D00000X
-----------------------------------------------------
Taxonomy Name | Emotionally Disturbed Childrens' Residential Treatment Facility
-----------------------------------------------------
License Number | 360908389
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------