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General NPI Number Information
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NPI Number | 1679009203
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Entity Type | Organization
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Legal Business Name | CHILDREN'S HOPE GROUP HOME
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Dates
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Enumeration Date | 05/02/2017
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Last Update Date | 05/02/2017
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Provider Practice Location Address
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Address Line | 1106 W 22ND ST
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City | UPLAND
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State | CA
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Zip | 91784-1231
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Country | US
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Telephone | 909-561-7784
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 1938
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City | UPLAND
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State | CA
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Zip | 91785-1938
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Country | US
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Telephone | 909-561-7784
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | MIKE SUDYKA
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Credential | LMFT
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Telephone | 909-561-7784
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 322D00000X
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Taxonomy Name | Emotionally Disturbed Childrens' Residential Treatment Facility
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License Number | 366425817
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License Number State | CA
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