Basic Information
Provider Information | |||||||||
NPI: | 1518400282 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | OPTIMIST BOYS' HOME AND RANCH, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | OPTIMIST MISSION HILLS | ||||||||
OtherOrganizationType: | 5 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 6957 N FIGUEROA ST | ||||||||
Address2: |   | ||||||||
City: | LOS ANGELES | ||||||||
State: | CA | ||||||||
PostalCode: | 900421245 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3234433175 | ||||||||
FaxNumber: | 3233445124 | ||||||||
Practice Location | |||||||||
Address1: | 14820 WOLFSKILL ST | ||||||||
Address2: |   | ||||||||
City: | MISSION HILLS | ||||||||
State: | CA | ||||||||
PostalCode: | 913451843 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3234433175 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/29/2016 | ||||||||
LastUpdateDate: | 12/05/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | ORLANDO | ||||||||
AuthorizedOfficialFirstName: | SILVIO | ||||||||
AuthorizedOfficialMiddleName: | JOHN | ||||||||
AuthorizedOfficialTitleorPosition: | CEO | ||||||||
AuthorizedOfficialTelephone: | 3234433127 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 323P00000X | 191201124 | CA | Y |   | Residential Treatment Facilities | Psychiatric Residential Treatment Facility |   |
ID Information
ID | Type | State | Issuer | Description | 00781 | 01 | CA | MEDI-CAL PROVIDER | OTHER |