Provider Demographics
NPI:1326599218
Name:BOYS & GIRLS CLUBS OF GARDEN GROVE
Entity Type:Organization
Organization Name:BOYS & GIRLS CLUBS OF GARDEN GROVE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIVISION DIRECTOR OF P&I
Authorized Official - Prefix:MS
Authorized Official - First Name:AMIE
Authorized Official - Middle Name:
Authorized Official - Last Name:LYNCH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:714-530-0430
Mailing Address - Street 1:10540 CHAPMAN AVE
Mailing Address - Street 2:
Mailing Address - City:GARDEN GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:92840-3101
Mailing Address - Country:US
Mailing Address - Phone:714-530-0430
Mailing Address - Fax:
Practice Address - Street 1:10540 CHAPMAN AVE
Practice Address - Street 2:
Practice Address - City:GARDEN GROVE
Practice Address - State:CA
Practice Address - Zip Code:92840-3101
Practice Address - Country:US
Practice Address - Phone:714-530-0430
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-17
Last Update Date:2016-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health