Healthcare Provider Details

I. General information

NPI: 1962930982
Provider Name (Legal Business Name): BOURNE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/03/2017
Last Update Date: 07/08/2022
Certification Date: 07/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1280 N HILL AVE
PASADENA CA
91104-3050
US

IV. Provider business mailing address

2235 LAKE AVE STE 212
ALTADENA CA
91001-6041
US

V. Phone/Fax

Practice location:
  • Phone: 626-797-9190
  • Fax:
Mailing address:
  • Phone: 626-797-9196
  • Fax: 626-345-9970

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: TIERRA MONIQUE PATTERSON
Title or Position: DIRECTOR OF CLINICAL SERVICES
Credential:
Phone: 909-587-7444