Provider Demographics
NPI:1568964021
Name:BOURNE INC
Entity Type:Organization
Organization Name:BOURNE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:TIM
Authorized Official - Middle Name:
Authorized Official - Last Name:TUCKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:626-786-1056
Mailing Address - Street 1:2235 LAKE AVE STE 212
Mailing Address - Street 2:
Mailing Address - City:ALTADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91001-6041
Mailing Address - Country:US
Mailing Address - Phone:626-797-9196
Mailing Address - Fax:626-345-9970
Practice Address - Street 1:3053 LA CORONA AVE
Practice Address - Street 2:
Practice Address - City:ALTADENA
Practice Address - State:CA
Practice Address - Zip Code:91001-4332
Practice Address - Country:US
Practice Address - Phone:626-791-3200
Practice Address - Fax:626-794-1252
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-01
Last Update Date:2019-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children