Provider Demographics
NPI:1285847301
Name:PEPPERMINT RIDGE
Entity Type:Organization
Organization Name:PEPPERMINT RIDGE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:A
Authorized Official - Last Name:GARRETT
Authorized Official - Suffix:
Authorized Official - Credentials:MSW
Authorized Official - Phone:9512-732-7320
Mailing Address - Street 1:825 MAGNOLIA AVE
Mailing Address - Street 2:
Mailing Address - City:CORONA
Mailing Address - State:CA
Mailing Address - Zip Code:92879-3129
Mailing Address - Country:US
Mailing Address - Phone:951-273-7320
Mailing Address - Fax:951-737-0726
Practice Address - Street 1:825 MAGNOLIA AVE
Practice Address - Street 2:
Practice Address - City:CORONA
Practice Address - State:CA
Practice Address - Zip Code:92879-3129
Practice Address - Country:US
Practice Address - Phone:951-273-7320
Practice Address - Fax:951-737-0726
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
CALTC60027FOtherEVERGREEN ESTATES