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General NPI Number Information
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NPI Number | 1245431808
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Entity Type | Organization
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Legal Business Name | BOYS & GIRLS CLUBS OF GARDEN GROVE
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Dates
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Enumeration Date | 05/30/2007
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Last Update Date | 12/06/2024
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Provider Practice Location Address
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Address Line | 13645 CLINTON ST
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City | GARDEN GROVE
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State | CA
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Zip | 92843
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Country | US
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Telephone | 714-530-0430
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Fax | 714-530-0431
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Provider Business Mailing Address
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Address Line | 10540 CHAPMAN AVE
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City | GARDEN GROVE
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State | CA
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Zip | 92840-3101
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Country | US
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Telephone | 714-530-0430
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Fax | 714-530-0431
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Authorized Official
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Title or Position | CEO
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Name | MARK SURMANIAN
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Credential |
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Telephone | 714-530-0430
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251B00000X
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Taxonomy Name | Case Management Agency
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 261QM0855X
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Taxonomy Name | Adolescent and Children Mental Health Clinic/Center
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License Number |
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License Number State |
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