Basic Information
| Provider Information | |||||||||
| NPI: | 1871043166 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PENNY LANE CENTERS | ||||||||
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| OtherOrganizationName: | PENNY LANE CENTERS-SATELLITE V | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 15305 RAYEN ST | ||||||||
| Address2: | |||||||||
| City: | NORTH HILLS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913435117 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8188923423 | ||||||||
| FaxNumber: | 8188923574 | ||||||||
| Practice Location | |||||||||
| Address1: | 8806 HASKELL AVE | ||||||||
| Address2: | |||||||||
| City: | NORTH HILLS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913434910 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8188942107 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/11/2016 | ||||||||
| LastUpdateDate: | 10/16/2016 | ||||||||
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| AuthorizedOfficialLastName: | LA FIANZA | ||||||||
| AuthorizedOfficialFirstName: | ROSANA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF CLINIC OPERATIONS | ||||||||
| AuthorizedOfficialTelephone: | 8188923423 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| AuthorizedOfficialCredential: | MBA | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 320800000X | 191202002 | CA | Y | Residential Treatment Facilities | Community Based Residential Treatment Facility, Mental Illness |
No ID Information.