Basic Information
| Provider Information | |||||||||
| NPI: | 1215404827 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FOOTHILL FAMILY SERVICE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2500 E FOOTHILL BLVD STE 300 | ||||||||
| Address2: | |||||||||
| City: | PASADENA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 911077102 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6269933000 | ||||||||
| FaxNumber: | 6269933084 | ||||||||
| Practice Location | |||||||||
| Address1: | 4701 WALNUT ST | ||||||||
| Address2: | |||||||||
| City: | BALDWIN PARK | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917062328 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6269933000 | ||||||||
| FaxNumber: | 6269933084 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/01/2018 | ||||||||
| LastUpdateDate: | 02/24/2020 | ||||||||
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| AuthorizedOfficialLastName: | SIEGRIST | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 6269933003 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | FOOTHILL FAMILY SERVICE | ||||||||
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| NPICertificationDate: | 02/24/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
No ID Information.