=====================================================
General NPI Number Information
=====================================================
NPI Number | 1750824637
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FRED JEFFERSON MEMORIAL HOME FOR BOYS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/28/2016
-----------------------------------------------------
Last Update Date | 03/03/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 152 W WALNUT ST SUITE 150
-----------------------------------------------------
City | GARDENA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90248-3141
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-763-1660
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 152 W WALNUT ST SUITE 150
-----------------------------------------------------
City | GARDENA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90248-3141
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-763-1660
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | NIQUELLE DEONDREA LEWIS
-----------------------------------------------------
Credential | MA
-----------------------------------------------------
Telephone | 310-763-1660
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 253J00000X
-----------------------------------------------------
Taxonomy Name | Foster Care Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------