Provider Demographics
NPI:1588816946
Name:GROVE DIVISION
Entity Type:Organization
Organization Name:GROVE DIVISION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:QMRP/ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:PARLUHUTAN
Authorized Official - Middle Name:WAHAB
Authorized Official - Last Name:SIREGAR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-624-2774
Mailing Address - Street 1:1422 GROVE AVE
Mailing Address - Street 2:
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91786-2841
Mailing Address - Country:US
Mailing Address - Phone:909-624-2774
Mailing Address - Fax:909-624-6014
Practice Address - Street 1:9140 MONTE VISTA AVE
Practice Address - Street 2:
Practice Address - City:MONTCLAIR
Practice Address - State:CA
Practice Address - Zip Code:91763-1723
Practice Address - Country:US
Practice Address - Phone:909-624-2774
Practice Address - Fax:909-624-6014
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MONTE VISTA CHILD CARE CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-10-16
Last Update Date:2008-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA240000529320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities