Healthcare Provider Details

I. General information

NPI: 1326172404
Provider Name (Legal Business Name): SAN GABRIEL CHILDREN'S CENTER INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/14/2007
Last Update Date: 05/01/2024
Certification Date: 05/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4740 N GRAND AVE
COVINA CA
91724-2005
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 TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number7563D
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License Number197804972
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License Number197804961
License Number StateCA
# 4
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number7563A
License Number StateCA

VIII. Authorized Official

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