Basic Information
| Provider Information | |||||||||
| NPI: | 1750824637 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FRED JEFFERSON MEMORIAL HOME FOR BOYS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 152 W WALNUT ST | ||||||||
| Address2: | SUITE 150 | ||||||||
| City: | GARDENA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 902483141 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3107631660 | ||||||||
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| Practice Location | |||||||||
| Address1: | 152 W WALNUT ST | ||||||||
| Address2: | SUITE 150 | ||||||||
| City: | GARDENA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 902483141 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3107631660 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/28/2016 | ||||||||
| LastUpdateDate: | 03/03/2020 | ||||||||
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| AuthorizedOfficialLastName: | LEWIS | ||||||||
| AuthorizedOfficialFirstName: | NIQUELLE | ||||||||
| AuthorizedOfficialMiddleName: | DEONDREA | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 3107631660 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MA | ||||||||
| NPICertificationDate: | 03/03/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 253J00000X | Y | Agencies | Foster Care Agency |
No ID Information.