Healthcare Provider Details

I. General information

NPI: 1023576261
Provider Name (Legal Business Name): RANCHO SAN ANTONIO BOYS HOME INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/06/2019
Last Update Date: 12/05/2024
Certification Date: 12/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21000 PLUMMER ST
CHATSWORTH CA
91311-4903
US

IV. Provider business mailing address

21000 PLUMMER ST
CHATSWORTH CA
91311-4903
US

V. Phone/Fax

Practice location:
  • Phone: 818-882-6400
  • Fax: 818-882-6404
Mailing address:
  • Phone: 818-882-6400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: KELLEY BUTLER
Title or Position: MENTAL HEALTH DIRECTOR
Credential: LCSW
Phone: 818-882-6400