Organization
PASA ALTA MANOR
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DEWALT BROWN MBA (CEO)
(626) 926-3519
Entity
Organization
Contact information
Practice address
1790 N FAIR OAKS AVE, PASADENA, CA 91103-1617
(626) 798-6986
(626) 798-5970
Mailing address
PO BOX 93577, PASADENA, CA 91109-3577
(626) 798-6986
(626) 798-5970
Taxonomy
Speciality
Code
Description
License number
State
320800000X
Mental Illness Community Based Residential Treatment Facility
Primary
191204078
CA
320900000X
Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
191222713
CA
320900000X
Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
197600074
CA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
191204078
ADULT RESIDENTIAL FACILITY LICENSE NUMBER
CA
01
—
191222713
ADULT RESIDENTIAL FACILITY LICENSE NUMBER
CA
01
—
197600074
ADULT RESIDENTIAL FACILITY LICENSE NUMBER
CA
Enumeration date
11/14/2011
Last updated
11/14/2011
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