Provider Demographics
NPI:1598208696
Name:OPTIMIST BOYS' HOME & RANCH, INC.
Entity Type:Organization
Organization Name:OPTIMIST BOYS' HOME & RANCH, INC.
Other - Org Name:PACIFIC LODGE CAMPUS
Other - Org Type:Other Name
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:TODD
Authorized Official - Middle Name:
Authorized Official - Last Name:SOSNA
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:323-443-3101
Mailing Address - Street 1:6957 N FIGUEROA ST
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90042-1245
Mailing Address - Country:US
Mailing Address - Phone:323-443-3175
Mailing Address - Fax:323-344-5124
Practice Address - Street 1:4900 SERRANIA AVE
Practice Address - Street 2:
Practice Address - City:WOODLAND HILLS
Practice Address - State:CA
Practice Address - Zip Code:91364-3301
Practice Address - Country:US
Practice Address - Phone:818-657-3123
Practice Address - Fax:818-347-1326
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-22
Last Update Date:2023-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA198209477323P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes323P00000XResidential Treatment FacilitiesPsychiatric Residential Treatment Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00781OtherMEDI-CAL PROVIDER