Provider Demographics
NPI:1679009203
Name:CHILDREN'S HOPE GROUP HOME
Entity Type:Organization
Organization Name:CHILDREN'S HOPE GROUP HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MIKE
Authorized Official - Middle Name:
Authorized Official - Last Name:SUDYKA
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:909-561-7784
Mailing Address - Street 1:PO BOX 1938
Mailing Address - Street 2:
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91785-1938
Mailing Address - Country:US
Mailing Address - Phone:909-561-7784
Mailing Address - Fax:
Practice Address - Street 1:1106 W 22ND ST
Practice Address - Street 2:
Practice Address - City:UPLAND
Practice Address - State:CA
Practice Address - Zip Code:91784-1231
Practice Address - Country:US
Practice Address - Phone:909-561-7784
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-02
Last Update Date:2017-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA366425817322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children