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General NPI Number Information
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NPI Number | 1508075508
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Entity Type | Organization
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Legal Business Name | PEPPERMINT RIDGE
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Dates
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Enumeration Date | 05/22/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 1581 HEARTLAND WAY
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City | CORONA
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State | CA
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Zip | 92881-4180
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Country | US
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Telephone | 951-273-7346
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Fax | 951-737-0726
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Provider Business Mailing Address
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Address Line | 825 MAGNOLIA AVE
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City | CORONA
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State | CA
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Zip | 92879-3129
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Country | US
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Telephone | 951-273-7320
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Fax | 951-737-0726
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | MR. JOHN A. GARRETT
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Credential | M.S.W.
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Telephone | 951-273-7320
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 320600000X
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Taxonomy Name | Intellectual and/or Developmental Disabilities Residential Treatment Facility
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License Number |
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License Number State | CA
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