Healthcare Provider Details

I. General information

NPI: 1366994279
Provider Name (Legal Business Name): SAN GABRIEL CHILDREN'S CENTER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/26/2016
Last Update Date: 12/15/2022
Certification Date: 12/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5329 N HOMEREST AVE
AZUSA CA
91702-5429
US

IV. Provider business mailing address

1211 CENTER COURT DR STE 105
COVINA CA
91724-3613
US

V. Phone/Fax

Practice location:
  • Phone: 626-859-2089
  • Fax: 626-859-6537
Mailing address:
  • Phone: 626-859-2089
  • Fax: 626-859-6537

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: MR. PORFIRIO RINCON
Title or Position: CEO
Credential:
Phone: 626-859-2089