Basic Information
Provider Information | |||||||||
NPI: | 1902027220 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | PROJECT SIX | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | MOUNTAINGATE HOME | ||||||||
OtherOrganizationType: | 5 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 13130 BURBANK BLVD | ||||||||
Address2: |   | ||||||||
City: | SHERMAN OAKS | ||||||||
State: | CA | ||||||||
PostalCode: | 914016037 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8187810360 | ||||||||
FaxNumber: | 8187795293 | ||||||||
Practice Location | |||||||||
Address1: | 13130 BURBANK BLVD | ||||||||
Address2: |   | ||||||||
City: | SHERMAN OAKS | ||||||||
State: | CA | ||||||||
PostalCode: | 914016037 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8187810360 | ||||||||
FaxNumber: | 8187795293 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/02/2007 | ||||||||
LastUpdateDate: | 08/22/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | FIRESTONE | ||||||||
AuthorizedOfficialFirstName: | BARBARA | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CEO - PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 8187810360 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 315P00000X | 96000608 | CA | Y |   | Nursing & Custodial Care Facilities | Intermediate Care Facility, Mentally Retarded |   |
No ID Information.