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General NPI Number Information
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NPI Number | 1568964021
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Entity Type | Organization
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Legal Business Name | BOURNE INC
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Dates
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Enumeration Date | 03/01/2018
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Last Update Date | 03/19/2019
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Provider Practice Location Address
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Address Line | 3053 LA CORONA AVE
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City | ALTADENA
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State | CA
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Zip | 91001-4332
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Country | US
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Telephone | 626-791-3200
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Fax | 626-794-1252
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Provider Business Mailing Address
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Address Line | 2235 LAKE AVE STE 212
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City | ALTADENA
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State | CA
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Zip | 91001-6041
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Country | US
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Telephone | 626-797-9196
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Fax | 626-345-9970
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Authorized Official
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Title or Position | CEO
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Name | TIM TUCKER
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Credential |
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Telephone | 626-786-1056
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 322D00000X
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Taxonomy Name | Emotionally Disturbed Childrens' Residential Treatment Facility
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License Number |
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License Number State |
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