Provider Demographics
NPI:1245407972
Name:GARDEN OF WILMINGTON
Entity Type:Organization
Organization Name:GARDEN OF WILMINGTON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BOARDING CARE ADMINISTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:THELMA
Authorized Official - Middle Name:
Authorized Official - Last Name:FLORES
Authorized Official - Suffix:
Authorized Official - Credentials:AD
Authorized Official - Phone:310-835-6366
Mailing Address - Street 1:1311 W ANAHEIM ST
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:CA
Mailing Address - Zip Code:90744-4109
Mailing Address - Country:US
Mailing Address - Phone:310-835-6366
Mailing Address - Fax:
Practice Address - Street 1:1311 W ANAHEIM ST
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:CA
Practice Address - Zip Code:90744-4109
Practice Address - Country:US
Practice Address - Phone:310-835-6366
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-12
Last Update Date:2008-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA191601613323P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes323P00000XResidential Treatment FacilitiesPsychiatric Residential Treatment Facility