Provider Demographics
NPI:1033987631
Name:MENTORS DRIVING CHANGE FOR BOYS, MEN AND DADS
Entity Type:Organization
Organization Name:MENTORS DRIVING CHANGE FOR BOYS, MEN AND DADS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR/PROGRAM DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DEUTRON
Authorized Official - Middle Name:
Authorized Official - Last Name:KEBEBEW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:831-588-7592
Mailing Address - Street 1:PO BOX 1585
Mailing Address - Street 2:
Mailing Address - City:FREEDOM
Mailing Address - State:CA
Mailing Address - Zip Code:95019-1585
Mailing Address - Country:US
Mailing Address - Phone:831-588-7592
Mailing Address - Fax:
Practice Address - Street 1:15 MADISON ST
Practice Address - Street 2:
Practice Address - City:WATSONVILLE
Practice Address - State:CA
Practice Address - Zip Code:95076-4490
Practice Address - Country:US
Practice Address - Phone:831-588-7592
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-12-13
Last Update Date:2023-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral Health
No172V00000XOther Service ProvidersCommunity Health WorkerGroup - Multi-Specialty