Provider Demographics
NPI:1124250378
Name:ROBERTS GROUP HOME INC
Entity type:Organization
Organization Name:ROBERTS GROUP HOME INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:HAZEL
Authorized Official - Middle Name:GERTRUDE
Authorized Official - Last Name:ROBERTS
Authorized Official - Suffix:
Authorized Official - Credentials:PERSONAL CARE PROVID
Authorized Official - Phone:909-623-3353
Mailing Address - Street 1:1435 EAST GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:POMONA
Mailing Address - State:CA
Mailing Address - Zip Code:91766
Mailing Address - Country:US
Mailing Address - Phone:909-623-3353
Mailing Address - Fax:909-623-1143
Practice Address - Street 1:1435 EAST GRAND AVE
Practice Address - Street 2:
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91766
Practice Address - Country:US
Practice Address - Phone:909-623-3353
Practice Address - Fax:909-623-1143
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-20
Last Update Date:2009-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA360906027320900000X
CA191592141320900000X
CA191501024320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities