Provider Demographics
NPI:1043482862
Name:LARCHMONT HOME
Entity Type:Organization
Organization Name:LARCHMONT HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSEE/CFO
Authorized Official - Prefix:MS
Authorized Official - First Name:YOLANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:RUIZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:650-303-0788
Mailing Address - Street 1:627 LARCHMONT DR
Mailing Address - Street 2:
Mailing Address - City:DALY CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94015-3637
Mailing Address - Country:US
Mailing Address - Phone:650-994-3673
Mailing Address - Fax:
Practice Address - Street 1:627 LARCHMONT DR
Practice Address - Street 2:
Practice Address - City:DALY CITY
Practice Address - State:CA
Practice Address - Zip Code:94015-3637
Practice Address - Country:US
Practice Address - Phone:650-994-3673
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:4JS HOME INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-04-01
Last Update Date:2008-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
CALTC60988FMedicaid