Basic Information
| Provider Information | |||||||||
| NPI: | 1063690204 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HELPING KIDS TO RECOVER, INC. | ||||||||
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| OtherOrganizationName: | LA VIDA WEST CAL- SAFE | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 637 E ALBERTONI ST | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | CARSON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 907461539 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3102170616 | ||||||||
| FaxNumber: | 3102170545 | ||||||||
| Practice Location | |||||||||
| Address1: | 14500 LARCH AVENUE | ||||||||
| Address2: | LA VIDA WEST CAL - SAFE | ||||||||
| City: | LAWNDALE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 902601621 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3102170616 | ||||||||
| FaxNumber: | 3102170545 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/08/2008 | ||||||||
| LastUpdateDate: | 02/08/2008 | ||||||||
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| AuthorizedOfficialLastName: | BOYD | ||||||||
| AuthorizedOfficialFirstName: | CHYNETHIA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | EXCUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 3102170616 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | HELPING KIDS TO RECOVER, INC. | ||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | M.B.A.,RAS | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 252Y00000X | N | Agencies | Early Intervention Provider Agency | 3245S0500X | Y | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility | Substance Abuse Treatment, Children |
ID Information
| ID | Type | State | Issuer | Description | 7247 | 05 | CA | MEDICAID |