Provider Demographics
NPI:1043784069
Name:CITADEL SHORT TERM SPECIALTY TREATMENT PROGRAMS
Entity Type:Organization
Organization Name:CITADEL SHORT TERM SPECIALTY TREATMENT PROGRAMS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ANNETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:PUNIMATA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-992-0929
Mailing Address - Street 1:568 N MOUNTAIN VIEW AVE
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92401-1231
Mailing Address - Country:US
Mailing Address - Phone:909-992-0929
Mailing Address - Fax:
Practice Address - Street 1:568 N MOUNTAIN VIEW AVE
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92401-1231
Practice Address - Country:US
Practice Address - Phone:909-992-0929
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CITADEL COMMUNITY CARE FACILITIES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-01-12
Last Update Date:2022-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
No251B00000XAgenciesCase Management
No322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
No324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
No3245S0500XResidential Treatment FacilitiesSubstance Abuse Rehabilitation FacilitySubstance Abuse Treatment, Children