Provider Demographics
NPI:1083305411
Name:BOYS REPUBLIC
Entity Type:Organization
Organization Name:BOYS REPUBLIC
Other - Org Name:BOYS REPUBLIC - ILP STRTP
Other - Org Type:Other Name
Authorized Official - Title/Position:CLINICAL SUPERVISOR/HEAD OF SERVICE
Authorized Official - Prefix:
Authorized Official - First Name:JUDITH
Authorized Official - Middle Name:
Authorized Official - Last Name:EDMUNDSON
Authorized Official - Suffix:
Authorized Official - Credentials:LPCC
Authorized Official - Phone:909-925-7693
Mailing Address - Street 1:1907 BOYS REPUBLIC DR
Mailing Address - Street 2:
Mailing Address - City:CHINO HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91709-5447
Mailing Address - Country:US
Mailing Address - Phone:909-628-1217
Mailing Address - Fax:909-306-5427
Practice Address - Street 1:3624 MARGARET FOWLER CT
Practice Address - Street 2:
Practice Address - City:CHINO HILLS
Practice Address - State:CA
Practice Address - Zip Code:91709-5456
Practice Address - Country:US
Practice Address - Phone:909-740-3133
Practice Address - Fax:909-306-5427
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BOYS REPUBLIC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2023-05-17
Last Update Date:2023-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness