Provider Demographics
NPI:1023576261
Name:RANCHO SAN ANTONIO BOYS HOME INC.
Entity Type:Organization
Organization Name:RANCHO SAN ANTONIO BOYS HOME INC.
Other - Org Name:RSA BRO JOHNS HOUSE STRTP
Other - Org Type:Other Name
Authorized Official - Title/Position:MENTAL HEALTH DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:KELLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:BUTLER
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:818-882-6400
Mailing Address - Street 1:21000 PLUMMER ST
Mailing Address - Street 2:
Mailing Address - City:CHATSWORTH
Mailing Address - State:CA
Mailing Address - Zip Code:91311-4903
Mailing Address - Country:US
Mailing Address - Phone:818-882-6400
Mailing Address - Fax:
Practice Address - Street 1:21000 PLUMMER ST
Practice Address - Street 2:
Practice Address - City:CHATSWORTH
Practice Address - State:CA
Practice Address - Zip Code:91311-4903
Practice Address - Country:US
Practice Address - Phone:818-882-6400
Practice Address - Fax:818-882-6404
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:RANCHO SAN ANTONIO BOYS HOME INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-03-06
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA19B7OtherMEDI-CAL PROVIDER
CA02172OtherLOS ANGELES COUNTY DEPARTMENT OF MENTAL HEALTH