Healthcare Provider Details

I. General information

NPI: 1730463548
Provider Name (Legal Business Name): EGGLESTON YOUTH CENTERS, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/29/2011
Last Update Date: 03/17/2020
Certification Date: 03/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3001 W VERNON AVE
LOS ANGELES CA
90008-5293
US

IV. Provider business mailing address

3001 W VERNON AVE
LOS ANGELES CA
90008-5293
US

V. Phone/Fax

Practice location:
  • Phone: 323-954-1464
  • Fax: 323-954-9515
Mailing address:
  • Phone: 323-954-1464
  • Fax: 323-954-9515

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code253J00000X
TaxonomyFoster Care Agency
License Number197805862
License Number StateCA

VIII. Authorized Official

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