Provider Demographics
NPI:1679178396
Name:PURPOSELY CHOSEN, INC.
Entity Type:Organization
Organization Name:PURPOSELY CHOSEN, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DRETONA
Authorized Official - Middle Name:TENESE
Authorized Official - Last Name:MADDOX
Authorized Official - Suffix:
Authorized Official - Credentials:RN, PHN, LCSW
Authorized Official - Phone:909-471-0697
Mailing Address - Street 1:1410 3RD ST STE 2
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92507-3454
Mailing Address - Country:US
Mailing Address - Phone:909-471-0697
Mailing Address - Fax:760-302-7607
Practice Address - Street 1:25030 OCOTILLO AVE
Practice Address - Street 2:
Practice Address - City:MORENO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92553-4440
Practice Address - Country:US
Practice Address - Phone:951-247-3000
Practice Address - Fax:760-302-7607
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PURPOSELY CHOSEN, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-12-01
Last Update Date:2020-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children