=====================================================
General NPI Number Information
=====================================================
NPI Number | 1821509563
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MCKINLEY CHILDREN'S CENTER, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/20/2017
-----------------------------------------------------
Last Update Date | 10/29/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 151 N FENIMORE AVE
-----------------------------------------------------
City | AZUSA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91702-3921
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 626-815-5132
-----------------------------------------------------
Fax | 626-815-6679
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 762 CYPRESS ST
-----------------------------------------------------
City | SAN DIMAS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91773-3505
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-599-1227
-----------------------------------------------------
Fax | 909-670-1584
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | ANIL VADAPARTY
-----------------------------------------------------
Credential | SPHR, ESQ.
-----------------------------------------------------
Telephone | 909-599-1227
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------