MEDICARE: FIELDS COMP. YOUTH SERVICES INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	322D00000X	Emotionally Disturbed Childrens' Residential Treatment Facility

General Provider Information

NPI Number	:	1295514149
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FIELDS COMP. YOUTH SERVICES INC.

Provider Business Mailing Address
First Line	:	8780 19TH ST # 196
Second Line	:
City	:	ALTA LOMA
State	:	CA
Zip	:	91701-4608
Country	:	US
Telephone Number	:	909-322-6980
Fax Number	:	909-466-4815

Provider Business Practice Location Address
First Line	:	2390 PORTOLA ST
Second Line	:
City	:	SAN BERNARDINO
State	:	CA
Zip	:	92407-6930
Country	:	US
Telephone Number	:	909-376-4148
Fax Number	:

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	ARBY ENRICO FIELDS
Credential	:
Telephone Number	:	909-322-6980

Provider Enumeration Date	:	09/28/2023
Last Update Date	:	09/28/2023

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