Healthcare Provider Details

I. General information

NPI: 1174066435
Provider Name (Legal Business Name): OPTIMIST BOYS HOME & RANCH, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/18/2016
Last Update Date: 05/22/2023
Certification Date: 05/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4900 SERRANIA AVE
WOODLAND HILLS CA
91364-3301
US

IV. Provider business mailing address

6957 N FIGUEROA ST
LOS ANGELES CA
90042-1245
US

V. Phone/Fax

Practice location:
  • Phone: 818-657-3123
  • Fax: 818-347-1326
Mailing address:
  • Phone: 323-443-3175
  • Fax: 323-344-5124

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: MR. TODD DAVID SOSNA
Title or Position: CEO
Credential: PH.D.
Phone: 323-443-3001