Provider Demographics
NPI:1548415904
Name:HACIENDA GRANDE
Entity Type:Organization
Organization Name:HACIENDA GRANDE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR RESIDENTIAL CARE
Authorized Official - Prefix:MR
Authorized Official - First Name:RODRIGO
Authorized Official - Middle Name:
Authorized Official - Last Name:RAMOS
Authorized Official - Suffix:
Authorized Official - Credentials:RESIDENTIAL CARE
Authorized Official - Phone:562-597-7753
Mailing Address - Street 1:1740 GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90804-2011
Mailing Address - Country:US
Mailing Address - Phone:562-597-7753
Mailing Address - Fax:562-597-7755
Practice Address - Street 1:1740 GRAND AVE
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90804-2011
Practice Address - Country:US
Practice Address - Phone:562-597-7753
Practice Address - Fax:562-597-7755
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-25
Last Update Date:2008-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA198205024323P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes323P00000XResidential Treatment FacilitiesPsychiatric Residential Treatment Facility