Basic Information
Provider Information | |||||||||
NPI: | 1568912483 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | FLEMING & BARNES, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | DIMONDALE ADOLESCENT | ||||||||
OtherOrganizationType: | 5 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 4446 | ||||||||
Address2: |   | ||||||||
City: | PALOS VERDES PENINSULA | ||||||||
State: | CA | ||||||||
PostalCode: | 902749595 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3107913064 | ||||||||
FaxNumber: | 3107913084 | ||||||||
Practice Location | |||||||||
Address1: | 1632 E DIMONDALE DR | ||||||||
Address2: |   | ||||||||
City: | CARSON | ||||||||
State: | CA | ||||||||
PostalCode: | 907462915 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3107913064 | ||||||||
FaxNumber: | 3106329078 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/04/2016 | ||||||||
LastUpdateDate: | 03/12/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | FLEMING | ||||||||
AuthorizedOfficialFirstName: | KENNETH | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 3107913064 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | FLEMING & BARNES, INC. | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 322D00000X | 198203822 | CA | Y |   | Residential Treatment Facilities | Residential Treatment Facility, Emotionally Disturbed Children |   |
No ID Information.