=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720514896
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TENDER LOVING CARE HOME FOR BOYS, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/10/2017
-----------------------------------------------------
Last Update Date | 05/10/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11519 CARLISLE PL
-----------------------------------------------------
City | RANCHO CUCAMONGA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91730-7233
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-484-7259
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11519 CARLISLE PLACE
-----------------------------------------------------
City | RANCHO CUCAMONGA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91730
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-484-7259
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | MR. REGINALD BROWN SR.
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 909-243-2307
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 322D00000X
-----------------------------------------------------
Taxonomy Name | Emotionally Disturbed Childrens' Residential Treatment Facility
-----------------------------------------------------
License Number | 366407775
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 322D00000X
-----------------------------------------------------
Taxonomy Name | Emotionally Disturbed Childrens' Residential Treatment Facility
-----------------------------------------------------
License Number | 366405647
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------