Provider Demographics
NPI:1831476589
Name:TYLER RESIDENTIAL CARE INC.
Entity Type:Organization
Organization Name:TYLER RESIDENTIAL CARE INC.
Other - Org Name:NONE
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:BENJAMIN
Authorized Official - Middle Name:TOLENTINO
Authorized Official - Last Name:PENALOSA
Authorized Official - Suffix:
Authorized Official - Credentials:ADMINISTRATOR
Authorized Official - Phone:714-394-7652
Mailing Address - Street 1:525 N GUADALUPE AVE
Mailing Address - Street 2:
Mailing Address - City:REDONDO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90277-2952
Mailing Address - Country:US
Mailing Address - Phone:714-394-7652
Mailing Address - Fax:
Practice Address - Street 1:6052 WESTERN AVE
Practice Address - Street 2:
Practice Address - City:BUENA PARK
Practice Address - State:CA
Practice Address - Zip Code:90621-2325
Practice Address - Country:US
Practice Address - Phone:714-521-0140
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-09
Last Update Date:2011-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA306000575320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities