Provider Demographics
NPI:1689998544
Name:HOLY TRINITY HOME
Entity Type:Organization
Organization Name:HOLY TRINITY HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/QMRP
Authorized Official - Prefix:MRS
Authorized Official - First Name:LYDIA
Authorized Official - Middle Name:SISON
Authorized Official - Last Name:SEBASTIAN
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:909-444-5796
Mailing Address - Street 1:3845 S MORGANFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:WEST COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91792-3238
Mailing Address - Country:US
Mailing Address - Phone:999-444-5796
Mailing Address - Fax:909-612-7675
Practice Address - Street 1:3845 S MORGANFIELD AVE
Practice Address - Street 2:
Practice Address - City:WEST COVINA
Practice Address - State:CA
Practice Address - Zip Code:91792-3238
Practice Address - Country:US
Practice Address - Phone:999-444-5796
Practice Address - Fax:909-612-7675
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-22
Last Update Date:2010-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities