=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679021679
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JILOA TREATMENT AND RECOVERY CENTERS INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/19/2016
-----------------------------------------------------
Last Update Date | 09/19/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 26340 KALMIA AVE
-----------------------------------------------------
City | MORENO VALLEY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92555-1720
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 951-203-4474
-----------------------------------------------------
Fax | 951-208-4491
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 26340 KALMIA AVE
-----------------------------------------------------
City | MORENO VALLEY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92555-1720
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 951-203-4474
-----------------------------------------------------
Fax | 951-208-4491
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | MR. KEITH DARNELL RHODES SR.
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 951-203-4474
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 320800000X
-----------------------------------------------------
Taxonomy Name | Mental Illness Community Based Residential Treatment Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 324500000X
-----------------------------------------------------
Taxonomy Name | Substance Abuse Rehabilitation Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------