Provider Demographics
NPI:1093473837
Name:PREMBO LLC
Entity Type:Organization
Organization Name:PREMBO LLC
Other - Org Name:SOCAL MENTAL HEALTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PRESTON
Authorized Official - Middle Name:JACK
Authorized Official - Last Name:DURNFORD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:760-409-7544
Mailing Address - Street 1:92 CORPORATE PARK STE C-200
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92606-5146
Mailing Address - Country:US
Mailing Address - Phone:760-409-7544
Mailing Address - Fax:
Practice Address - Street 1:23711 VIA NAVARRA
Practice Address - Street 2:
Practice Address - City:MISSION VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92691-3637
Practice Address - Country:US
Practice Address - Phone:760-409-7544
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-11-29
Last Update Date:2022-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes323P00000XResidential Treatment FacilitiesPsychiatric Residential Treatment Facility