Provider Demographics
NPI:1962930859
Name:BOYS REPUBLIC
Entity type:Organization
Organization Name:BOYS REPUBLIC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:RESIDENCE CLINICAL SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:ELLEN
Authorized Official - Middle Name:
Authorized Official - Last Name:STRICKLAND
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:909-287-6433
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 1:128 E PALM AVE
Practice Address - Street 2:
Practice Address - City:MONROVIA
Practice Address - State:CA
Practice Address - Zip Code:91016-5108
Practice Address - Country:US
Practice Address - Phone:626-358-4581
Practice Address - Fax:909-627-9222
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BOYS REPUBLIC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-05-23
Last Update Date:2022-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health