Basic Information
| Provider Information | |||||||||
| NPI: | 1871946442 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BOYS & GIRLS CLUBS OF GARDEN GROVE, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10540 CHAPMAN AVE | ||||||||
| Address2: | |||||||||
| City: | GARDEN GROVE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 928403101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7145300430 | ||||||||
| FaxNumber: | 7145300431 | ||||||||
| Practice Location | |||||||||
| Address1: | 11301 ACACIA PKWY | ||||||||
| Address2: | |||||||||
| City: | GARDEN GROVE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 928405310 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7147415895 | ||||||||
| FaxNumber: | 7146360351 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/19/2016 | ||||||||
| LastUpdateDate: | 07/19/2016 | ||||||||
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| AuthorizedOfficialLastName: | SURMANIAN | ||||||||
| AuthorizedOfficialFirstName: | MARK | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 7145300430 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 252Y00000X | Y | Agencies | Early Intervention Provider Agency |
No ID Information.