Provider Demographics
NPI:1992890057
Name:ETTIE LEE HOMES, INC
Entity type:Organization
Organization Name:ETTIE LEE HOMES, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:QA MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:WINDY
Authorized Official - Middle Name:
Authorized Official - Last Name:LUNA PEREZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-620-2521
Mailing Address - Street 1:303 W FOOTHILL BLVD STE 13
Mailing Address - Street 2:
Mailing Address - City:GLENDORA
Mailing Address - State:CA
Mailing Address - Zip Code:91741-3386
Mailing Address - Country:US
Mailing Address - Phone:626-960-4861
Mailing Address - Fax:626-960-6241
Practice Address - Street 1:160 E HOLT AVE STE B
Practice Address - Street 2:
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91767-5407
Practice Address - Country:US
Practice Address - Phone:909-620-2521
Practice Address - Fax:909-620-9793
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-04
Last Update Date:2024-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
253J00000X, 261QM0855X
CAC07933322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
No253J00000XAgenciesFoster Care Agency
No322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA36IHCROtherSBCDBH
CA7453AOtherLACDMH
CA7712AOtherMENTAL HEALTH
CA7008OtherDRUG & ALCOHOL