=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356972772
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TENDER LOVING CARE HOME FOR BOYS, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/04/2020
-----------------------------------------------------
Last Update Date | 02/04/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7839 PATRIOT PL
-----------------------------------------------------
City | RANCHO CUCAMONGA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91730-2640
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-948-2898
-----------------------------------------------------
Fax | 909-466-7840
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7839 PATRIOT PL
-----------------------------------------------------
City | RANCHO CUCAMONGA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91730-2640
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-243-2307
-----------------------------------------------------
Fax | 909-477-2619
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | DESIA DUNN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 909-749-5764
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 322D00000X
-----------------------------------------------------
Taxonomy Name | Emotionally Disturbed Childrens' Residential Treatment Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------