Basic Information
Provider Information | |||||||||
NPI: | 1427442557 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | FIVE ACRES- THE BOYS' AND GIRLS' AID SOCIETY OF LOS ANGELES COUNTY | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | FIVE ACRES | ||||||||
OtherOrganizationType: | 5 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 760 MOUNTAIN VIEW ST | ||||||||
Address2: |   | ||||||||
City: | ALTADENA | ||||||||
State: | CA | ||||||||
PostalCode: | 910014925 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6267986793 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 7356 PAINTER AVE | ||||||||
Address2: | 102 | ||||||||
City: | WHITTIER | ||||||||
State: | CA | ||||||||
PostalCode: | 906021853 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6267986793 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/26/2015 | ||||||||
LastUpdateDate: | 10/10/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | SHANKLIN | ||||||||
AuthorizedOfficialFirstName: | SHAULON | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | DIRECTOF OF CLAIMS OPERATIONS | ||||||||
AuthorizedOfficialTelephone: | 6267989763 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251300000X |   |   | N |   | Agencies | Local Education Agency (LEA) |   | 251B00000X |   |   | N |   | Agencies | Case Management |   | 251K00000X |   |   | N |   | Agencies | Public Health or Welfare |   | 252Y00000X |   |   | N |   | Agencies | Early Intervention Provider Agency |   | 251S00000X |   |   | Y |   | Agencies | Community/Behavioral Health |   |
No ID Information.