Provider Demographics
NPI:1538322656
Name:WANDA
Entity Type:Organization
Organization Name:WANDA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LVN
Authorized Official - Prefix:MS
Authorized Official - First Name:WANDA
Authorized Official - Middle Name:JEAN
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:LVN
Authorized Official - Phone:909-496-2440
Mailing Address - Street 1:3730 FERNWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:RIALTO
Mailing Address - State:CA
Mailing Address - Zip Code:92377-2724
Mailing Address - Country:US
Mailing Address - Phone:909-823-3703
Mailing Address - Fax:909-823-3703
Practice Address - Street 1:3730 FERNWOOD AVE
Practice Address - Street 2:
Practice Address - City:RIALTO
Practice Address - State:CA
Practice Address - Zip Code:92377-2724
Practice Address - Country:US
Practice Address - Phone:909-823-3703
Practice Address - Fax:909-823-3703
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-09
Last Update Date:2023-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA320700000X320700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320700000XResidential Treatment FacilitiesResidential Treatment Facility, Physical Disabilities