Basic Information
| Provider Information | |||||||||
| NPI: | 1629518147 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MCKINLEY CHILDREN'S CENTER | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| OtherOrganizationName: | MCKINLEY-STRTP | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 762 CYPRESS ST | ||||||||
| Address2: | |||||||||
| City: | SAN DIMAS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917733505 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9095991227 | ||||||||
| FaxNumber: | 9095923841 | ||||||||
| Practice Location | |||||||||
| Address1: | 762 CYPRESS ST | ||||||||
| Address2: | |||||||||
| City: | SAN DIMAS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917733505 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9095991227 | ||||||||
| FaxNumber: | 9095923841 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/02/2017 | ||||||||
| LastUpdateDate: | 12/13/2017 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | VADAPARTY | ||||||||
| AuthorizedOfficialFirstName: | ANIL | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 9095991227 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MCKINLEY CHILDREN'S CENTER | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | SPHR, ESQ. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 322D00000X | 191502075 | CA | Y | Residential Treatment Facilities | Residential Treatment Facility, Emotionally Disturbed Children |
No ID Information.