Healthcare Provider Details

I. General information

NPI: 1114361102
Provider Name (Legal Business Name): FONTHILL GARDENS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/22/2013
Last Update Date: 04/22/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14103 FONTHILL AVE
HAWTHORNE CA
90250-8013
US

IV. Provider business mailing address

14103 FONTHILL AVE
HAWTHORNE CA
90250-8013
US

V. Phone/Fax

Practice location:
  • Phone: 310-973-7242
  • Fax: 310-973-7147
Mailing address:
  • Phone: 310-973-7242
  • Fax: 310-973-7147

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3104A0625X
TaxonomyAssisted Living Facility (Mental Illness)
License Number198204690
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code323P00000X
TaxonomyPsychiatric Residential Treatment Facility
License Number198204690
License Number StateCA

VIII. Authorized Official

Name: DR. RAHMAT HUSSAIN KHAN
Title or Position: C.E.O
Credential: FACS
Phone: 310-873-7242