1649517764 NPI number — EGGLESTON YOUTH CENTERS, INC.

Table of content: (NPI 1649517764)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649517764 NPI number — EGGLESTON YOUTH CENTERS, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EGGLESTON YOUTH CENTERS, INC.
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:
Provider Other Organization Name Type Code:
6
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:
1649517764
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/16/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
13001 RAMONA BLVD., SUITE E
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
IRWINDALE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91706
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
626-627-6000
Provider Business Mailing Address Fax Number:
626-480-7688

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
13001 RAMONA BLVD STE E
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
IRWINDALE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91706-3752
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
626-480-8107
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/09/2013

Additional Information

Authorized Official

Authorized Official Last Name:
GIBSON-JUDKINS
Authorized Official First Name:
CASSANDRA
Authorized Official Middle Name:
ELAINE
Authorized Official Title or Position:
ASSISTANT EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
626-480-8107

Provider Taxonomy Codes

  • Taxonomy code: 324500000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 7427 . This is a "DRUG MEDI-CAL BILLING NO." identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 190716AN . This is a "DEPT OF ALCOHOL AND DRUG PROGRAMS" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 197427 . This is a "MASTER PROVIDER FILE NO." identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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