Provider Demographics
NPI:1467622290
Name:KNOTTS GROUP HOME
Entity Type:Organization
Organization Name:KNOTTS GROUP HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:GWEN
Authorized Official - Middle Name:
Authorized Official - Last Name:KNOTTS
Authorized Official - Suffix:
Authorized Official - Credentials:MSN
Authorized Official - Phone:909-880-0600
Mailing Address - Street 1:1505 W HIGHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92411-1215
Mailing Address - Country:US
Mailing Address - Phone:909-880-0600
Mailing Address - Fax:909-473-1918
Practice Address - Street 1:1505 W HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92411-1215
Practice Address - Country:US
Practice Address - Phone:909-880-0600
Practice Address - Fax:909-473-1918
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-07
Last Update Date:2008-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health