Provider Demographics
NPI:1578879599
Name:DEBOER HOME #2
Entity Type:Organization
Organization Name:DEBOER HOME #2
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSEE
Authorized Official - Prefix:
Authorized Official - First Name:BREANN
Authorized Official - Middle Name:
Authorized Official - Last Name:DEBOER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:559-350-3695
Mailing Address - Street 1:2211 W ORANGE AVENUE
Mailing Address - Street 2:
Mailing Address - City:PORTERVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:93257-7000
Mailing Address - Country:US
Mailing Address - Phone:559-350-3695
Mailing Address - Fax:559-793-2718
Practice Address - Street 1:2211 W ORANGE AVE
Practice Address - Street 2:
Practice Address - City:PORTERVILLE
Practice Address - State:CA
Practice Address - Zip Code:93257-7305
Practice Address - Country:US
Practice Address - Phone:559-350-3695
Practice Address - Fax:559-793-2718
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-27
Last Update Date:2010-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA550001291320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities