=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679289318
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DIAKONIA, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/26/2023
-----------------------------------------------------
Last Update Date | 01/26/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5589 N RIVERSIDE AVE
-----------------------------------------------------
City | RIALTO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92377-3967
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-873-9248
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5589 N RIVERSIDE AVE
-----------------------------------------------------
City | RIALTO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92377-3967
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-873-9248
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | TIFFANY MERRITT
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 909-278-4312
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 322D00000X
-----------------------------------------------------
Taxonomy Name | Emotionally Disturbed Childrens' Residential Treatment Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------