Basic Information
| Provider Information | |||||||||
| NPI: | 1730381880 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SAN GABRIEL CHILDRENS CENTER INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4740 N GRAND AVE | ||||||||
| Address2: | |||||||||
| City: | COVINA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917242005 | ||||||||
| 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: | 06/01/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | RINCON | ||||||||
| AuthorizedOfficialFirstName: | PORFIRIO | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT CEO | ||||||||
| AuthorizedOfficialTelephone: | 6268592089 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | MA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | 7274A | CA | X | Agencies | Community/Behavioral Health | 251S00000X | 7274D | CA | X | Agencies | Community/Behavioral Health | 322D00000X | CA | X | Residential Treatment Facilities | Residential Treatment Facility, Emotionally Disturbed Children | 322D00000X | CA | X | Residential Treatment Facilities | Residential Treatment Facility, Emotionally Disturbed Children | 322D00000X | CA | X | Residential Treatment Facilities | Residential Treatment Facility, Emotionally Disturbed Children | 322D00000X | CA | X | Residential Treatment Facilities | Residential Treatment Facility, Emotionally Disturbed Children | 322D00000X | CA | X | Residential Treatment Facilities | Residential Treatment Facility, Emotionally Disturbed Children | 322D00000X | CA | X | Residential Treatment Facilities | Residential Treatment Facility, Emotionally Disturbed Children |
ID Information
| ID | Type | State | Issuer | Description | 0000056BJ | 05 | CA | MEDICAID |