Basic Information
Provider Information | |||||||||
NPI: | 1417407719 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | PENNY LANE CENTERS | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | PENNY LANE CENTERS-SATELLITE VI | ||||||||
OtherOrganizationType: | 5 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 15305 RAYEN ST | ||||||||
Address2: |   | ||||||||
City: | NORTH HILLS | ||||||||
State: | CA | ||||||||
PostalCode: | 913435117 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8188923423 | ||||||||
FaxNumber: | 8188923574 | ||||||||
Practice Location | |||||||||
Address1: | 11641 BALBOA BLVD | ||||||||
Address2: |   | ||||||||
City: | GRANADA HILLS | ||||||||
State: | CA | ||||||||
PostalCode: | 913442710 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8183609342 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/11/2016 | ||||||||
LastUpdateDate: | 10/16/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | LA FIANZA | ||||||||
AuthorizedOfficialFirstName: | ROSANA | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | DIRECTOR OF CLINIC OPERATIONS | ||||||||
AuthorizedOfficialTelephone: | 8188923423 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MBA | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 320800000X | 191202002 | CA | Y |   | Residential Treatment Facilities | Community Based Residential Treatment Facility, Mental Illness |   |
No ID Information.