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General NPI Number Information
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NPI Number | 1679781884
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Entity Type | Organization
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Legal Business Name | L. MARILLAC GROUP HOME
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Dates
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Enumeration Date | 05/19/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 23711 PROSPECT VALLEY DR
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City | DIAMOND BAR
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State | CA
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Zip | 91765-1637
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Country | US
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Telephone | 909-821-3698
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Fax | 909-860-7614
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Provider Business Mailing Address
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Address Line | 23711 PROSPECT VALLEY DR
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City | DIAMOND BAR
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State | CA
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Zip | 91765-1637
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Country | US
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Telephone | 909-821-3698
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Fax | 909-860-7614
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Authorized Official
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Title or Position | LICENSEE
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Name | GRACE VILLEGAS
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Credential |
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Telephone | 909-821-3698
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 315P00000X
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Taxonomy Name | Intellectual Disabilities Intermediate Care Facility
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License Number |
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License Number State | CA
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