Provider Demographics
NPI:1255879417
Name:DAVID AND MARGARET HOME, INC.
Entity type:Organization
Organization Name:DAVID AND MARGARET HOME, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:
Authorized Official - Last Name:RICH
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:909-596-5921
Mailing Address - Street 1:1350 3RD ST
Mailing Address - Street 2:
Mailing Address - City:LA VERNE
Mailing Address - State:CA
Mailing Address - Zip Code:91750-5201
Mailing Address - Country:US
Mailing Address - Phone:909-596-5921
Mailing Address - Fax:909-596-7583
Practice Address - Street 1:1350 3RD ST
Practice Address - Street 2:
Practice Address - City:LA VERNE
Practice Address - State:CA
Practice Address - Zip Code:91750-5201
Practice Address - Country:US
Practice Address - Phone:909-596-5921
Practice Address - Fax:909-596-7583
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DAVID AND MARGARET HOME, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-02-08
Last Update Date:2017-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA191500192322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA01227Medicaid