Provider Demographics
NPI:1205384559
Name:SAN GABRIEL CHILDRENS CENTER INC.
Entity Type:Organization
Organization Name:SAN GABRIEL CHILDRENS CENTER INC.
Other - Org Name:SGCC-HOMEREST HOME
Other - Org Type:Other Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:PORFIRIO
Authorized Official - Middle Name:
Authorized Official - Last Name:RINCON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:626-859-2089
Mailing Address - Street 1:1211 CENTER COURT DR STE 105
Mailing Address - Street 2:
Mailing Address - City:COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91724-3613
Mailing Address - Country:US
Mailing Address - Phone:626-859-2089
Mailing Address - Fax:626-859-6537
Practice Address - Street 1:5329 N HOMEREST AVE
Practice Address - Street 2:
Practice Address - City:AZUSA
Practice Address - State:CA
Practice Address - Zip Code:91702-5429
Practice Address - Country:US
Practice Address - Phone:626-859-2089
Practice Address - Fax:626-859-6537
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-15
Last Update Date:2022-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0000056BJMedicaid