=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366619082
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FOUNDER'S HOUSE OF HOPE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/12/2008
-----------------------------------------------------
Last Update Date | 05/12/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 18025 PIONEER BLVD
-----------------------------------------------------
City | ARTESIA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90701-3904
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 562-860-3351
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 18025 PIONEER BLVD
-----------------------------------------------------
City | ARTESIA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90701-3904
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 562-860-3351
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADULT CARETAKE ADMINISTOR
-----------------------------------------------------
Name | MR. MICHAEL BOLONG
-----------------------------------------------------
Credential | AD
-----------------------------------------------------
Telephone | 562-860-3351
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 323P00000X
-----------------------------------------------------
Taxonomy Name | Psychiatric Residential Treatment Facility
-----------------------------------------------------
License Number | 191592599
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------