Basic Information
| Provider Information | |||||||||
| NPI: | 1023576261 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | RANCHO SAN ANTONIO BOYS HOME INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 21000 PLUMMER ST | ||||||||
| Address2: | |||||||||
| City: | CHATSWORTH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913114903 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8188826400 | ||||||||
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| Practice Location | |||||||||
| Address1: | 21000 PLUMMER ST | ||||||||
| Address2: | |||||||||
| City: | CHATSWORTH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913114903 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8188826400 | ||||||||
| FaxNumber: | 8188826404 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/06/2019 | ||||||||
| LastUpdateDate: | 06/11/2019 | ||||||||
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| AuthorizedOfficialLastName: | BUTLER | ||||||||
| AuthorizedOfficialFirstName: | KELLEY | ||||||||
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| AuthorizedOfficialTitleorPosition: | MENTAL HEALTH DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 8188826400 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | RANCHO SAN ANTONIO BOYS HOME INC. | ||||||||
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| AuthorizedOfficialCredential: | LCSW | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 320800000X | Y | Residential Treatment Facilities | Community Based Residential Treatment Facility, Mental Illness |
ID Information
| ID | Type | State | Issuer | Description | 02172 | 01 | CA | LOS ANGELES COUNTY DEPARTMENT OF MENTAL HEALTH | OTHER | 19B7 | 01 | CA | MEDI-CAL PROVIDER | OTHER |