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General NPI Number Information
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NPI Number | 1891167912
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Entity Type | Organization
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Legal Business Name | HABILITATIVE HOMES RESIDENTIAL CARE FACILITY
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Dates
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Enumeration Date | 10/28/2015
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Last Update Date | 03/16/2016
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Provider Practice Location Address
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Address Line | 11775 WALNUT RD
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City | LAKESIDE
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State | CA
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Zip | 92040-5624
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Country | US
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Telephone | 619-270-4484
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Fax |
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Provider Business Mailing Address
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Address Line | 11775 WALNUT ROAD
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City | LAKESIDE
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State | CA
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Zip | 92040
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Country | US
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Telephone | 619-270-4484
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Fax |
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Authorized Official
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Title or Position | LICENEE/OWNER/ADMINISTRATOR
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Name | DAVID CLARENCE LARSON
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Credential |
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Telephone | 619-456-3742
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 320800000X
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Taxonomy Name | Mental Illness Community Based Residential Treatment Facility
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License Number | 374603669
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License Number State | CA
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Taxonomy #2
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Taxonomy Code | 3104A0630X
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Taxonomy Name | Assisted Living Facility (Behavioral Disturbances)
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License Number | 374603669
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License Number State | CA
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Taxonomy #3
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Taxonomy Code | 311ZA0620X
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Taxonomy Name | Adult Care Home Facility
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License Number | 374603669
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License Number State | CA
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Taxonomy #4
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Taxonomy Code | 310400000X
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Taxonomy Name | Assisted Living Facility
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License Number | 374603669
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License Number State | CA
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