=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720105224
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FIVE ACRES- THE BOYS' AND GIRLS' AID SOCIETY OF LOS ANGELES COUNTY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/22/2007
-----------------------------------------------------
Last Update Date | 09/22/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 867 N FAIR OAKS AVE
-----------------------------------------------------
City | PASADENA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91103-3083
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 626-798-6793
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 760 W. MOUNTAIN VIEW STREET
-----------------------------------------------------
City | ALTADENA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91001-4925
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 626-798-6793
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR OF CLAIMS OPERATIONS
-----------------------------------------------------
Name | SHAULON SHANKLIN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 626-798-6793
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251B00000X
-----------------------------------------------------
Taxonomy Name | Case Management Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 251C00000X
-----------------------------------------------------
Taxonomy Name | Developmentally Disabled Services Day Training Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------