1427334721 NPI number — A SECOND CHANCE

Table of content: (NPI 1427334721)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1427334721 NPI number — A SECOND CHANCE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
A SECOND CHANCE
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
CALIFORNIA MENTAL HEALTH CONNECTION
Provider Other Organization Name Type Code:
4
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1427334721
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/31/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
707 N FOXDALE AVE
Provider Second Line Business Mailing Address:
714 N. SUNSET AVE
Provider Business Mailing Address City Name:
WEST COVINA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91790-1213
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
626-430-6197
Provider Business Mailing Address Fax Number:
626-430-7404

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
707 N FOXDALE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WEST COVINA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91790-1213
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
626-430-6197
Provider Business Practice Location Address Fax Number:
626-430-7404
Provider Enumeration Date:
10/31/2011

Additional Information

Authorized Official

Authorized Official Last Name:
HAKIMIAN
Authorized Official First Name:
VAHE
Authorized Official Middle Name:
A
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
626-430-6197

Provider Taxonomy Codes

  • Taxonomy code: 251K00000X , with the licence number:  BBS4936 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 251S00000X , with the licence number: 162257 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 390200000X . This is a "SINGLE SPECIALITY GROUP" identifier . This identifiers is of the category "OTHER".
  • Identifier: 390200000X . This is a "STUDENT IN AN ORGANIZED HEALTH CARE EDUCATION TRAINING PROGRAM" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 261Q00000X . This is a "COMMUNITY CLINIC CENTER" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: BBS4936 . This is a "AGENCY" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: AGENCY . This is a "VICITMS OF CRIME" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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