Provider Demographics
NPI:1720357627
Name:EGGLESTON YOUTH CENTERS, INC.
Entity Type:Organization
Organization Name:EGGLESTON YOUTH CENTERS, INC.
Other - Org Name:EGGLESTON SUBSTANCE ABUSE AND EDUCATION PROGRAM
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ASSISTANT EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:CASSANDRA
Authorized Official - Middle Name:ELAINE
Authorized Official - Last Name:GIBSON-JUDKINS
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:626-480-8107
Mailing Address - Street 1:13001 RAMONA BLVD STE J
Mailing Address - Street 2:
Mailing Address - City:IRWINDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91706-3752
Mailing Address - Country:US
Mailing Address - Phone:626-480-8107
Mailing Address - Fax:
Practice Address - Street 1:13001 RAMONA BLVD STE J
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:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EGGLESTON YOUTH CENTERS, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-12-21
Last Update Date:2018-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA7427OtherMEDI-CAL