Basic Information
| Provider Information | |||||||||
| NPI: | 1649722554 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SAN GABRIEL CHILDREN'S CENTER, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SGCC ENID HOME-AC | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 337 SOUTH ENID AVE | ||||||||
| Address2: | |||||||||
| City: | AZUSA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917024302 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6268592089 | ||||||||
| FaxNumber: | 6268596537 | ||||||||
| Practice Location | |||||||||
| Address1: | 337 SOUTH ENID AVE | ||||||||
| Address2: | |||||||||
| City: | AZUSA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917024302 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6268592089 | ||||||||
| FaxNumber: | 6268596537 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/26/2016 | ||||||||
| LastUpdateDate: | 09/18/2019 | ||||||||
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| AuthorizedOfficialLastName: | RINCON | ||||||||
| AuthorizedOfficialFirstName: | PORFIRIO | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 6268592089 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 322D00000X | Y | Residential Treatment Facilities | Residential Treatment Facility, Emotionally Disturbed Children |
ID Information
| ID | Type | State | Issuer | Description | 0000056BJ | 05 | CA | MEDICAID |