1871622498 NPI number — OPTIMIST BOYS' HOME AND RANCH, INC.

Table of content: (NPI 1871622498)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1871622498 NPI number — OPTIMIST BOYS' HOME AND RANCH, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
OPTIMIST BOYS' HOME AND RANCH, 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:
1871622498
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/21/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6957 N FIGUEROA ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOS ANGELES
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90042-1245
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
323-443-3175
Provider Business Mailing Address Fax Number:
323-344-5124

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
41307 12TH ST W STE 105&201
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PALMDALE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
93551-1445
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
323-443-3175
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/02/2007

Additional Information

Authorized Official

Authorized Official Last Name:
CERVANTES
Authorized Official First Name:
RUSHMORE
Authorized Official Middle Name:
Authorized Official Title or Position:
CHIEF EXECUTIVE OFFICER
Authorized Official Telephone Number:
323-443-3101

Provider Taxonomy Codes

  • Taxonomy code: 171M00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 251S00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 00781 . This is a "MEDI-CAL PROVIDER" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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