Basic Information
| Provider Information | |||||||||
| NPI: | 1669508974 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FOOTHILL FAMILY SERVICE | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | FOOTHILL FAMILY SERVICE - COVINA | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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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: | 530 W BADILLO ST | ||||||||
| Address2: | |||||||||
| City: | COVINA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917223787 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6269933000 | ||||||||
| FaxNumber: | 6269933093 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/23/2007 | ||||||||
| LastUpdateDate: | 06/18/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SIEGRIST | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 6269933003 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 06/18/2020 | ||||||||
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.