Healthcare Provider Details

I. General information

NPI: 1386181550
Provider Name (Legal Business Name): EGGLESTON YOUTH CENTERS, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/26/2017
Last Update Date: 10/02/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

340 N WESTRIDGE AVE
COVINA CA
91724-2921
US

IV. Provider business mailing address

13001 RAMONA BLVD STE E
IRWINDALE CA
91706-3752
US

V. Phone/Fax

Practice location:
  • Phone: 626-480-8107
  • Fax: 626-869-0280
Mailing address:
  • Phone: 626-480-8107
  • Fax: 626-869-0280

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License Number197806369
License Number StateCA

VIII. Authorized Official

Name: CASSANDRA ELAINE GIBSON-JUDKINS
Title or Position: ASSISTANT EXECUTIVE DIRECTOR
Credential: LCSW
Phone: 626-480-8107