Provider Demographics
NPI:1437287828
Name:PENNY GENEVIEVE HARGROVE
Entity Type:Organization
Organization Name:PENNY GENEVIEVE HARGROVE
Other - Org Name:WINGS I
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:PENNY
Authorized Official - Middle Name:
Authorized Official - Last Name:HARGROVE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:925-754-5184
Mailing Address - Street 1:P.O. BOX 1295
Mailing Address - Street 2:
Mailing Address - City:ANTIOCH
Mailing Address - State:CA
Mailing Address - Zip Code:94509-0129
Mailing Address - Country:US
Mailing Address - Phone:925-776-8386
Mailing Address - Fax:
Practice Address - Street 1:2427 DESRYS BLVD
Practice Address - Street 2:
Practice Address - City:ANTIOCH
Practice Address - State:CA
Practice Address - Zip Code:94509-4324
Practice Address - Country:US
Practice Address - Phone:925-776-8386
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-28
Last Update Date:2008-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALTC60761F320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities