Organization
HABILITATIVE HOMES RESIDENTIAL CARE FACILITY
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DAVID CLARENCE LARSON (LICENEE/OWNER/ADMINISTRATOR)
(619) 456-3742
Entity
Organization
Contact information
Practice address
11775 WALNUT RD, LAKESIDE, CA 92040-5624
(619) 270-4484
Mailing address
11775 WALNUT ROAD, LAKESIDE, CA 92040
(619) 270-4484
Taxonomy
Speciality
Code
Description
License number
State
310400000X
Assisted Living Facility
Primary
374603669
CA
3104A0630X
Assisted Living Facility (Behavioral Disturbances)
374603669
CA
311ZA0620X
Adult Care Home Facility
374603669
CA
320800000X
Mental Illness Community Based Residential Treatment Facility
374603669
CA
Other
Enumeration date
10/28/2015
Last updated
03/16/2016
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