Provider Demographics
NPI:1346791100
Name:RUNNYMEDE GROUP HOME
Entity Type:Organization
Organization Name:RUNNYMEDE GROUP HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JORGE
Authorized Official - Middle Name:C
Authorized Official - Last Name:MARQUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:818-592-2960
Mailing Address - Street 1:22455 VICTORY BLVD
Mailing Address - Street 2:
Mailing Address - City:WEST HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91307
Mailing Address - Country:US
Mailing Address - Phone:818-592-2960
Mailing Address - Fax:818-592-2961
Practice Address - Street 1:15352 RUNNYMEDE
Practice Address - Street 2:
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91405
Practice Address - Country:US
Practice Address - Phone:818-988-9042
Practice Address - Fax:818-988-9042
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CHILDREN'S HOMES OF SOUTHERN CALIFORNIA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-10-17
Last Update Date:2016-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA191221595322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children