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General NPI Number Information
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NPI Number | 1629964341
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Entity Type | Organization
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Legal Business Name | MAYBERRY'S
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Dates
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Enumeration Date | 06/17/2025
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Last Update Date | 06/17/2025
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Provider Practice Location Address
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Address Line | 14516 TACUBA DR
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City | LA MIRADA
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State | CA
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Zip | 90638-2043
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Country | US
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Telephone | 310-650-0545
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 6296
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City | LAKEWOOD
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State | CA
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Zip | 90714-6296
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DEBRA BALLOU-HARDING
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Credential |
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Telephone | 310-650-0545
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 3104A0625X
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Taxonomy Name | Assisted Living Facility (Mental Illness)
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 3104A0630X
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Taxonomy Name | Assisted Living Facility (Behavioral Disturbances)
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 311ZA0620X
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Taxonomy Name | Adult Care Home Facility
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License Number |
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License Number State |
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Taxonomy #4
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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 |
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Taxonomy #5
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Taxonomy Code | 310400000X
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Taxonomy Name | Assisted Living Facility
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License Number |
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License Number State |
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