Basic Information
| Provider Information | |||||||||
| NPI: | 1750408241 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FIVE ACRES- THE BOYS' AND GIRLS' AID SOCIETY OF LOS ANGELES COUNTY | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | FIVE ACRES | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 760 W. MOUNTAIN VIEW ST | ||||||||
| Address2: | |||||||||
| City: | ALTADENA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 910014925 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6267986793 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2934 E GARVEY AVE S | ||||||||
| Address2: | (SUITE) 100A-102-242 | ||||||||
| City: | WEST COVINA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917912190 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6267986793 | ||||||||
| FaxNumber: | 6262140303 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/22/2007 | ||||||||
| LastUpdateDate: | 08/20/2021 | ||||||||
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| AuthorizedOfficialLastName: | SHANKLIN | ||||||||
| AuthorizedOfficialFirstName: | SHAULON | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF CLAIMS OPERATIONS | ||||||||
| AuthorizedOfficialTelephone: | 6267986793 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 08/20/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251B00000X | N | Agencies | Case Management | 251S00000X | Y | Agencies | Community/Behavioral Health |
No ID Information.