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General NPI Number Information
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NPI Number | 1750587507
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Entity Type | Organization
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Legal Business Name | PROTOTYPES
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Dates
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Enumeration Date | 06/26/2007
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Last Update Date | 07/21/2022
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Provider Practice Location Address
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Address Line | 3755 VALLE VISTA DR
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City | CHINO HILLS
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State | CA
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Zip | 91709-2943
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Country | US
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Telephone | 909-606-6166
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Fax |
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Provider Business Mailing Address
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Address Line | 3755 VALLE VISTA DR
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City | CHINO HILLS
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State | CA
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Zip | 91709-2943
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Country | US
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Telephone | 909-606-6166
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Fax |
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Authorized Official
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Title or Position | CHILD CARE SPECIALIST
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Name | DENISE SUSAN BOUZID
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Credential |
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Telephone | 909-606-6166
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 3245S0500X
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Taxonomy Name | Children's Substance Abuse Rehabilitation Facility
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License Number |
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License Number State | CA
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