Provider Demographics
NPI:1518142512
Name:MASADA/EGGLESTON
Entity Type:Organization
Organization Name:MASADA/EGGLESTON
Other - Org Name:EGGLESTON YOUTH CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:
Authorized Official - Last Name:IGI
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:310-715-2020
Mailing Address - Street 1:108 W VICTORIA ST
Mailing Address - Street 2:
Mailing Address - City:GARDENA
Mailing Address - State:CA
Mailing Address - Zip Code:90248-3523
Mailing Address - Country:US
Mailing Address - Phone:310-715-2020
Mailing Address - Fax:
Practice Address - Street 1:13001 RAMONA BLVD STE E
Practice Address - Street 2:
Practice Address - City:IRWINDALE
Practice Address - State:CA
Practice Address - Zip Code:91706-3752
Practice Address - Country:US
Practice Address - Phone:626-480-8107
Practice Address - Fax:626-480-7688
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-08
Last Update Date:2008-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health