Basic Information
Provider Information | |||||||||
NPI: | 1821507021 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | MCKINLEY CHILDREN'S CENTER, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | LONE HILL INTERMEDIATE SCHOOL | ||||||||
OtherOrganizationType: | 5 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 762 CYPRESS ST | ||||||||
Address2: |   | ||||||||
City: | SAN DIMAS | ||||||||
State: | CA | ||||||||
PostalCode: | 917733505 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9095991227 | ||||||||
FaxNumber: | 9096701584 | ||||||||
Practice Location | |||||||||
Address1: | 700 S LONE HILL AVE | ||||||||
Address2: |   | ||||||||
City: | SAN DIMAS | ||||||||
State: | CA | ||||||||
PostalCode: | 91773 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9099718270 | ||||||||
FaxNumber: | 9099718279 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/20/2017 | ||||||||
LastUpdateDate: | 10/29/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | VADAPARTY | ||||||||
AuthorizedOfficialFirstName: | ANIL | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CEO | ||||||||
AuthorizedOfficialTelephone: | 9095991227 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | MCKINLEY CHILDREN'S CENTER, INC. | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | SPHR, ESQ | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | 191502075 | CA | Y |   | Agencies | Community/Behavioral Health |   |
No ID Information.