Provider Demographics
NPI:1538399191
Name:ESSEX BOARD AND CARE FACILITY
Entity type:Organization
Organization Name:ESSEX BOARD AND CARE FACILITY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:ALFONSO
Authorized Official - Middle Name:A
Authorized Official - Last Name:LOTA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-591-0791
Mailing Address - Street 1:11220 ESSEX AVE
Mailing Address - Street 2:
Mailing Address - City:POMONA
Mailing Address - State:CA
Mailing Address - Zip Code:91766-4048
Mailing Address - Country:US
Mailing Address - Phone:909-591-0791
Mailing Address - Fax:
Practice Address - Street 1:11220 ESSEX AVE
Practice Address - Street 2:
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91766-4048
Practice Address - Country:US
Practice Address - Phone:909-591-0791
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-17
Last Update Date:2009-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA360911118320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities