Provider Demographics
NPI:1356032817
Name:BOYS REPUBLIC
Entity type:Organization
Organization Name:BOYS REPUBLIC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CLINICAL SUPERVISOR/HEAD OF SERVICE
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:ROA
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:909-925-8134
Mailing Address - Street 1:1907 BOYS REPUBLIC DR
Mailing Address - Street 2:
Mailing Address - City:CHINO HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91709-5447
Mailing Address - Country:US
Mailing Address - Phone:909-628-1217
Mailing Address - Fax:909-306-5427
Practice Address - Street 1:3606 JOHN WATKINS WAY
Practice Address - Street 2:
Practice Address - City:CHINO HILLS
Practice Address - State:CA
Practice Address - Zip Code:91709-5453
Practice Address - Country:US
Practice Address - Phone:909-740-3136
Practice Address - Fax:909-306-5427
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BOYS REPUBLIC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2023-05-16
Last Update Date:2023-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness