Provider Demographics
NPI:1528195609
Name:IMMACULATE CARE CENTR INC.
Entity Type:Organization
Organization Name:IMMACULATE CARE CENTR INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JAPHET
Authorized Official - Middle Name:
Authorized Official - Last Name:OKEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:951-243-0303
Mailing Address - Street 1:24384 SUNNYMEAD BLVD STE 240
Mailing Address - Street 2:
Mailing Address - City:MORENO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92553-7765
Mailing Address - Country:US
Mailing Address - Phone:951-243-0303
Mailing Address - Fax:951-243-3006
Practice Address - Street 1:24384 SUNNYMEAD BLVD STE 240
Practice Address - Street 2:
Practice Address - City:MORENO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92553-7765
Practice Address - Country:US
Practice Address - Phone:951-243-0303
Practice Address - Fax:951-243-3006
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA13102101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty