Provider Demographics
NPI:1417407719
Name:PENNY LANE CENTERS
Entity Type:Organization
Organization Name:PENNY LANE CENTERS
Other - Org Name:PENNY LANE CENTERS-SATELLITE VI
Other - Org Type:Other Name
Authorized Official - Title/Position:DIRECTOR OF CLINIC OPERATIONS
Authorized Official - Prefix:MS
Authorized Official - First Name:ROSANA
Authorized Official - Middle Name:
Authorized Official - Last Name:LA FIANZA
Authorized Official - Suffix:
Authorized Official - Credentials:MBA
Authorized Official - Phone:818-892-3423
Mailing Address - Street 1:15305 RAYEN ST
Mailing Address - Street 2:
Mailing Address - City:NORTH HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91343-5117
Mailing Address - Country:US
Mailing Address - Phone:818-892-3423
Mailing Address - Fax:818-892-3574
Practice Address - Street 1:11641 BALBOA BLVD
Practice Address - Street 2:
Practice Address - City:GRANADA HILLS
Practice Address - State:CA
Practice Address - Zip Code:91344-2710
Practice Address - Country:US
Practice Address - Phone:818-360-9342
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-11
Last Update Date:2016-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA191202002320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness