Healthcare Provider Details

I. General information

NPI: 1720520513
Provider Name (Legal Business Name): BETHANY CHRISTIAN SERVICES OF SOUNTHERN CA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/09/2016
Last Update Date: 11/09/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4001 MISSION OAKS BLVD SUITE T & K
CAMARILLO CA
93012-5121
US

IV. Provider business mailing address

16700 VALLEY VIEW AVE SUITE 210
LA MIRADA CA
90638-5830
US

V. Phone/Fax

Practice location:
  • Phone: 805-482-2423
  • Fax:
Mailing address:
  • Phone: 714-994-0500
  • Fax: 714-994-0515

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code253J00000X
TaxonomyFoster Care Agency
License Number197804198
License Number StateCA

VIII. Authorized Official

Name: JEFFREY PAUL CARLSON
Title or Position: REGIONAL DIRECTOR
Credential: MFT
Phone: 714-994-0500