Healthcare Provider Details

I. General information

NPI: 1972053726
Provider Name (Legal Business Name): FIVE ACRES- THE BOYS' AND GIRLS' AID SOCIETY OF LOS ANGELES COUNTY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/05/2016
Last Update Date: 08/20/2021
Certification Date: 08/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1236 SOLITA RD
PASADENA CA
91103-2452
US

IV. Provider business mailing address

760 W. MOUNTAIN VIEW ST
ALTADENA CA
91001-4925
US

V. Phone/Fax

Practice location:
  • Phone: 626-798-6793
  • Fax: 626-792-7722
Mailing address:
  • Phone: 626-798-6793
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: SHAULON SHANKLIN
Title or Position: DIRECTOR OF CLAIMS OPERATIONS
Credential:
Phone: 626-798-6793