MEDICARE: ALPHA RESIDENTIAL 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	315P00000X	Intellectual Disabilities Intermediate Care Facility	550002479	CA

General Provider Information

NPI Number	:	1508376955
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ALPHA RESIDENTIAL INC

Provider Business Mailing Address
First Line	:	PO BOX 2220
Second Line	:
City	:	POMONA
State	:	CA
Zip	:	91769-2220
Country	:	US
Telephone Number	:	909-815-1129
Fax Number	:	909-622-2090

Provider Business Practice Location Address
First Line	:	692 SAN BERNARDINO AVE
Second Line	:
City	:	POMONA
State	:	CA
Zip	:	91767-3244
Country	:	US
Telephone Number	:	909-620-2585
Fax Number	:	909-622-2090

Authorized Official
Title or Position	:	PRESIDENT
Name	:	VINCENT OKORAFOR
Credential	:
Telephone Number	:	909-629-1829

Provider Enumeration Date	:	10/11/2017
Last Update Date	:	03/17/2018

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Directions to “ALPHA RESIDENTIAL INC ” Practice Location

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