Provider Demographics
NPI:1336426717
Name:PASA ALTA MANOR
Entity type:Organization
Organization Name:PASA ALTA MANOR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:DEWALT
Authorized Official - Middle Name:
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:MBA
Authorized Official - Phone:626-926-3519
Mailing Address - Street 1:PO BOX 93577
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91109-3577
Mailing Address - Country:US
Mailing Address - Phone:626-798-6986
Mailing Address - Fax:626-798-5970
Practice Address - Street 1:1790 N FAIR OAKS AVE
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91103-1617
Practice Address - Country:US
Practice Address - Phone:626-798-6986
Practice Address - Fax:626-798-5970
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-14
Last Update Date:2011-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA191204078320800000X
CA191222713320900000X
CA197600074320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
No320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA191204078OtherADULT RESIDENTIAL FACILITY LICENSE NUMBER
CA191222713OtherADULT RESIDENTIAL FACILITY LICENSE NUMBER
CA197600074OtherADULT RESIDENTIAL FACILITY LICENSE NUMBER