Healthcare Provider Details

I. General information

NPI: 1841168424
Provider Name (Legal Business Name): KENNEDY AUSTIN FOUNDATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/27/2025
Last Update Date: 03/10/2026
Certification Date: 03/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2040 N GAREY AVE
POMONA CA
91767-2722
US

IV. Provider business mailing address

PO BOX 1013
POMONA CA
91769-1013
US

V. Phone/Fax

Practice location:
  • Phone: 909-808-6866
  • Fax:
Mailing address:
  • Phone: 951-475-0742
  • Fax: 951-475-0742

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QR0400X
TaxonomyRehabilitation Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ETHEL M GARDNER
Title or Position: C.E.O
Credential:
Phone: 951-475-0742