Provider Demographics
NPI:1083158810
Name:HILLSIDES
Entity Type:Organization
Organization Name:HILLSIDES
Other - Org Name:BIENVENIDOS VILLAGE
Other - Org Type:Other Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:STACEY
Authorized Official - Middle Name:
Authorized Official - Last Name:ROTH
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:323-254-2274
Mailing Address - Street 1:13001 RAMONA BLVD.
Mailing Address - Street 2:SUITE A
Mailing Address - City:IRWINDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91706-3752
Mailing Address - Country:US
Mailing Address - Phone:626-373-2900
Mailing Address - Fax:626-798-7899
Practice Address - Street 1:13001 RAMONA BLVD.
Practice Address - Street 2:SUITE A
Practice Address - City:IRWINDALE
Practice Address - State:CA
Practice Address - Zip Code:91706-3752
Practice Address - Country:US
Practice Address - Phone:323-274-3075
Practice Address - Fax:626-798-7899
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HILLSIDES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-12-13
Last Update Date:2023-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health