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General NPI Number Information
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NPI Number | 1508131491
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Entity Type | Organization
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Legal Business Name | OUR LADY OF MERCY HOME 2
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Dates
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Enumeration Date | 03/12/2012
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Last Update Date | 03/12/2012
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Provider Practice Location Address
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Address Line | 3845 S MORGANFIELD AVE
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City | WEST COVINA
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State | CA
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Zip | 91792-3238
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Country | US
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Telephone | 909-444-5796
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Fax | 909-594-3604
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Provider Business Mailing Address
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Address Line | 3845 S MORGANFIELD AVE
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City | WEST COVINA
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State | CA
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Zip | 91792-3238
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Country | US
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Telephone | 909-444-5796
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Fax | 909-594-3604
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Authorized Official
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Title or Position | OWNER/LICENCEE
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Name | MRS. LYDIA S DEBASTIAN
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Credential | RN
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Telephone | 909-578-5453
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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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