Provider Demographics
NPI:1235585944
Name:CALIFORNIA MENTOR
Entity Type:Organization
Organization Name:CALIFORNIA MENTOR
Other - Org Name:NATIONAL MENTOR HEALTHCARE, LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PROJECT DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:HEATHER
Authorized Official - Middle Name:
Authorized Official - Last Name:DIAZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-948-7385
Mailing Address - Street 1:9166 ANAHEIM PL
Mailing Address - Street 2:SUITE 200
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91730-8541
Mailing Address - Country:US
Mailing Address - Phone:909-483-2505
Mailing Address - Fax:909-483-2119
Practice Address - Street 1:824 18TH ST
Practice Address - Street 2:
Practice Address - City:BAKERSFIELD
Practice Address - State:CA
Practice Address - Zip Code:93301-4824
Practice Address - Country:US
Practice Address - Phone:661-322-4085
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NATIONAL MENTOR, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-05-11
Last Update Date:2016-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA07000048251C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services