Provider Demographics
NPI:1730780313
Name:ORCHID COURT, INC.
Entity type:Organization
Organization Name:ORCHID COURT, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:CLODOVEO
Authorized Official - Middle Name:R
Authorized Official - Last Name:GOSUICO III
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-884-3044
Mailing Address - Street 1:307 S ARROWHEAD AVENUE
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92408-1325
Mailing Address - Country:US
Mailing Address - Phone:909-884-3044
Mailing Address - Fax:909-884-3044
Practice Address - Street 1:307 S ARROWHEAD AVENUE
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92408-1325
Practice Address - Country:US
Practice Address - Phone:909-884-3044
Practice Address - Fax:909-884-3044
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ORCHID COURT, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-11-02
Last Update Date:2020-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness