Basic Information
Provider Information | |||||||||
NPI: | 1679016554 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | FRED JEFFERSON MEMORIAL HOME FOR BOYS | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | FRED JEFFERSON MEMORIAL HOME #1 | ||||||||
OtherOrganizationType: | 5 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 152 W WALNUT ST | ||||||||
Address2: | SUITE 150 | ||||||||
City: | GARDENA | ||||||||
State: | CA | ||||||||
PostalCode: | 902483141 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3107631660 | ||||||||
FaxNumber: | 3107630357 | ||||||||
Practice Location | |||||||||
Address1: | 1000 W 152ND ST | ||||||||
Address2: |   | ||||||||
City: | COMPTON | ||||||||
State: | CA | ||||||||
PostalCode: | 902202821 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3107631660 | ||||||||
FaxNumber: | 3107630357 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/28/2016 | ||||||||
LastUpdateDate: | 03/03/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | LEWIS | ||||||||
AuthorizedOfficialFirstName: | NIQUELLE | ||||||||
AuthorizedOfficialMiddleName: | DEONDREA | ||||||||
AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 3107631660 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MA | ||||||||
NPICertificationDate: | 03/03/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 322D00000X |   |   | Y |   | Residential Treatment Facilities | Residential Treatment Facility, Emotionally Disturbed Children |   |
No ID Information.