Basic Information
| Provider Information | |||||||||
| NPI: | 1326172404 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SAN GABRIEL CHILDREN'S CENTER INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | SAN GABRIEL CHILDREN'S CENTER OUTPATIENT | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1211 CENTER COURT DR STE 105 | ||||||||
| Address2: | |||||||||
| City: | COVINA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917243613 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6268592089 | ||||||||
| FaxNumber: | 6268596537 | ||||||||
| Practice Location | |||||||||
| Address1: | 4740 N GRAND AVE | ||||||||
| Address2: | |||||||||
| City: | COVINA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917242005 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6268592089 | ||||||||
| FaxNumber: | 6268596537 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/14/2007 | ||||||||
| LastUpdateDate: | 05/18/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | RINCON | ||||||||
| AuthorizedOfficialFirstName: | PORFIRIO | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT/CEO | ||||||||
| AuthorizedOfficialTelephone: | 6268592089 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 05/18/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | 7563D | CA | N | Agencies | Community/Behavioral Health | 322D00000X | 197804972 | CA | N | Residential Treatment Facilities | Residential Treatment Facility, Emotionally Disturbed Children | 322D00000X | 197804961 | CA | N | Residential Treatment Facilities | Residential Treatment Facility, Emotionally Disturbed Children | 251S00000X | 7563A | CA | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 0000056BJ | 05 | CA | MEDICAID |