Provider Demographics
NPI:1215489000
Name:BOYS REPUBLIC
Entity type:Organization
Organization Name:BOYS REPUBLIC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CLINICIAN/HEAD OF SERVICE
Authorized Official - Prefix:
Authorized Official - First Name:BAYLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:DARK
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:909-536-6611
Mailing Address - Street 1:1907 BOYS REPUBLIC DR
Mailing Address - Street 2:
Mailing Address - City:CHINO HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91709-5447
Mailing Address - Country:US
Mailing Address - Phone:909-628-1217
Mailing Address - Fax:909-627-9222
Practice Address - Street 1:733 N GAREY AVE
Practice Address - Street 2:
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91767
Practice Address - Country:US
Practice Address - Phone:909-622-3556
Practice Address - Fax:909-306-5427
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BOYS REPUBLIC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-10-27
Last Update Date:2022-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
No251S00000XAgenciesCommunity/Behavioral Health