Provider Demographics
NPI:1649165358
Name:YUCAIPA VALLEY PEDIATRIC LIVING INC
Entity type:Organization
Organization Name:YUCAIPA VALLEY PEDIATRIC LIVING INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSEE
Authorized Official - Prefix:
Authorized Official - First Name:HANAH
Authorized Official - Middle Name:J
Authorized Official - Last Name:MALCOLM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-499-0804
Mailing Address - Street 1:12193 CUSTER ST
Mailing Address - Street 2:
Mailing Address - City:YUCAIPA
Mailing Address - State:CA
Mailing Address - Zip Code:92399-4485
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12193 CUSTER ST
Practice Address - Street 2:
Practice Address - City:YUCAIPA
Practice Address - State:CA
Practice Address - Zip Code:92399-4485
Practice Address - Country:US
Practice Address - Phone:909-499-0804
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-06-11
Last Update Date:2025-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3140N1450XNursing & Custodial Care FacilitiesSkilled Nursing FacilityNursing Care, Pediatric