Basic Information
| Provider Information | |||||||||
| NPI: | 1518446624 | ||||||||
| 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: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 760 W. MOUNTAIN VIEW ST | ||||||||
| Address2: | |||||||||
| City: | ALTADENA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 910014925 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6267986793 | ||||||||
| FaxNumber: | 6267927722 | ||||||||
| Practice Location | |||||||||
| Address1: | 760 W. MOUNTAIN VIEW ST | ||||||||
| Address2: | |||||||||
| City: | ALTADENA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 910014925 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6267986793 | ||||||||
| FaxNumber: | 6267927722 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/09/2018 | ||||||||
| LastUpdateDate: | 08/20/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SHANKLIN | ||||||||
| AuthorizedOfficialFirstName: | SHAULON | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF CLAIMS OPERATIONS | ||||||||
| AuthorizedOfficialTelephone: | 6269933134 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | FIVE ACRES | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 08/20/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251300000X | N | Agencies | Local Education Agency (LEA) | 251K00000X | N | Agencies | Public Health or Welfare | 252Y00000X | N | Agencies | Early Intervention Provider Agency | 251S00000X | Y | Agencies | Community/Behavioral Health |
No ID Information.