MEDICARE: CASA MONTANA LLC

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	251C00000X	Developmentally Disabled Services Day Training Agency

General Provider Information

NPI Number	:	1679952717
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CASA MONTANA LLC

Provider Business Mailing Address
First Line	:	1758 BIG DALTON AVE
Second Line	:
City	:	BALDWIN PARK
State	:	CA
Zip	:	91706-5910
Country	:	US
Telephone Number	:	626-962-3274
Fax Number	:	626-337-2969

Provider Business Practice Location Address
First Line	:	1922 N MOUNTAIN AVE
Second Line	:
City	:	CLAREMONT
State	:	CA
Zip	:	91711-2605
Country	:	US
Telephone Number	:	626-962-3274
Fax Number	:	626-337-2969

Authorized Official
Title or Position	:	DIRECTOR BUSINESS DEVELOPMENT
Name	:	MR. RICH RUIZ
Credential	:
Telephone Number	:	626-701-4635

Provider Enumeration Date	:	05/21/2015
Last Update Date	:	05/29/2015

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