MEDICARE: BOURNE INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	322D00000X	Emotionally Disturbed Childrens' Residential Treatment Facility

General Provider Information

NPI Number	:	1568964021
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BOURNE INC

Provider Business Mailing Address
First Line	:	2235 LAKE AVE STE 212
Second Line	:
City	:	ALTADENA
State	:	CA
Zip	:	91001-6041
Country	:	US
Telephone Number	:	626-797-9196
Fax Number	:	626-345-9970

Provider Business Practice Location Address
First Line	:	3053 LA CORONA AVE
Second Line	:
City	:	ALTADENA
State	:	CA
Zip	:	91001-4332
Country	:	US
Telephone Number	:	626-791-3200
Fax Number	:	626-794-1252

Authorized Official
Title or Position	:	CEO
Name	:	TIM TUCKER
Credential	:
Telephone Number	:	626-786-1056

Provider Enumeration Date	:	03/01/2018
Last Update Date	:	05/08/2026

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Directions to “BOURNE INC ” Practice Location

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