Provider Demographics
NPI:1164682829
Name:SEVBENOA, INC.
Entity Type:Organization
Organization Name:SEVBENOA, INC.
Other - Org Name:SCOVILLE VILLA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:MILAGROS
Authorized Official - Middle Name:
Authorized Official - Last Name:SAMSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-624-9107
Mailing Address - Street 1:1244 SCOVILLE AVE
Mailing Address - Street 2:
Mailing Address - City:POMONA
Mailing Address - State:CA
Mailing Address - Zip Code:91767-3450
Mailing Address - Country:US
Mailing Address - Phone:909-624-9107
Mailing Address - Fax:909-350-0495
Practice Address - Street 1:1244 SCOVILLE AVE
Practice Address - Street 2:
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91767-3450
Practice Address - Country:US
Practice Address - Phone:909-624-9107
Practice Address - Fax:909-350-0495
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-16
Last Update Date:2008-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities