Healthcare Provider Details

I. General information

NPI: 1114051240
Provider Name (Legal Business Name): FIVE ACRES- THE BOYS' AND GIRLS' AID SOCIETY OF LOS ANGELES COUNTY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/14/2007
Last Update Date: 10/10/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

760 WEST MOUNTAIN VIEW STREET
ALTADENA CA
91001
US

IV. Provider business mailing address

760 WEST MOUNTAIN VIEW STREET
ALTADENA CA
91001-4925
US

V. Phone/Fax

Practice location:
  • Phone: 626-798-6793
  • Fax: 626-792-7722
Mailing address:
  • Phone: 626-798-6793
  • Fax: 626-792-7722

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: SHAULON SHANKLIN
Title or Position: DIRECTOR OF CLAIMS OPERATIONS
Credential: MBA
Phone: 626-798-6793