Provider Demographics
NPI:1326172404
Name:SAN GABRIEL CHILDREN'S CENTER INC.
Entity Type:Organization
Organization Name:SAN GABRIEL CHILDREN'S CENTER INC.
Other - Org Name:SAN GABRIEL CHILDREN'S CENTER OUTPATIENT
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT/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 1:4740 N GRAND AVE
Practice Address - Street 2:
Practice Address - City:COVINA
Practice Address - State:CA
Practice Address - Zip Code:91724-2005
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:2007-03-14
Last Update Date:2024-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA7563D251S00000X
CA7563A251S00000X
CA197804972322D00000X
CA197804961322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0000056BJMedicaid