Provider Demographics
NPI:1609859461
Name:CONGREGATIONAL HOMES
Entity Type:Organization
Organization Name:CONGREGATIONAL HOMES
Other - Org Name:MT SAN ANTONIO GARDENS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:C.F.O.
Authorized Official - Prefix:MS
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:CFO
Authorized Official - Phone:909-399-1281
Mailing Address - Street 1:900 E HARRISON AVE
Mailing Address - Street 2:
Mailing Address - City:POMONA
Mailing Address - State:CA
Mailing Address - Zip Code:91767-2075
Mailing Address - Country:US
Mailing Address - Phone:909-624-5061
Mailing Address - Fax:909-626-2126
Practice Address - Street 1:900 E HARRISON AVE
Practice Address - Street 2:
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91767-2075
Practice Address - Country:US
Practice Address - Phone:909-624-5061
Practice Address - Fax:909-626-2126
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-25
Last Update Date:2016-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA191500496310400000X
CA950000078314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA055016Medicare Oscar/Certification
CA556516Medicare ID - Type UnspecifiedREHAB