Healthcare Provider Details

I. General information

NPI: 1073112157
Provider Name (Legal Business Name): 10-20 CLUB INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/20/2020
Last Update Date: 12/05/2022
Certification Date: 12/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10810 PARAMOUNT BLVD STE 202
DOWNEY CA
90241-3351
US

IV. Provider business mailing address

10810 PARAMOUNT BLVD STE 202
DOWNEY CA
90241-3351
US

V. Phone/Fax

Practice location:
  • Phone: 562-294-3315
  • Fax:
Mailing address:
  • Phone: 562-294-3315
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL

VIII. Authorized Official

Name: RONNIE FERNANDEZ
Title or Position: EXECUTIVE DIRECTOR
Credential: LCSW
Phone: 323-793-3595