Provider Demographics
NPI:1164296653
Name:LINDENHURST VPAN
Entity Type:Organization
Organization Name:LINDENHURST VPAN
Other - Org Name:SOCAL YOUTH UNITED
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ANGELIKA
Authorized Official - Middle Name:
Authorized Official - Last Name:PANOVA
Authorized Official - Suffix:
Authorized Official - Credentials:PMHNP-RN, LMFT
Authorized Official - Phone:714-887-3816
Mailing Address - Street 1:1057 E IMPERIAL HWY # 226
Mailing Address - Street 2:
Mailing Address - City:PLACENTIA
Mailing Address - State:CA
Mailing Address - Zip Code:92870-1717
Mailing Address - Country:US
Mailing Address - Phone:714-887-3816
Mailing Address - Fax:209-203-1061
Practice Address - Street 1:16365 PICK PL
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92504-5638
Practice Address - Country:US
Practice Address - Phone:714-887-3816
Practice Address - Fax:209-203-1061
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-11-14
Last Update Date:2024-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health