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General NPI Number Information
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NPI Number | 1649165358
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Entity Type | Organization
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Legal Business Name | YUCAIPA VALLEY PEDIATRIC LIVING INC
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Dates
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Enumeration Date | 06/11/2025
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Last Update Date | 06/11/2025
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Provider Practice Location Address
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Address Line | 12193 CUSTER ST
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City | YUCAIPA
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State | CA
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Zip | 92399-4485
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Country | US
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Telephone | 909-499-0804
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Fax |
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Provider Business Mailing Address
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Address Line | 12193 CUSTER ST
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City | YUCAIPA
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State | CA
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Zip | 92399-4485
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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 | LICENSEE
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Name | HANAH J MALCOLM
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Credential |
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Telephone | 909-499-0804
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 3140N1450X
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Taxonomy Name | Pediatric Skilled Nursing Facility
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License Number |
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License Number State |
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