Provider Demographics
NPI:1760753990
Name:POM POM CASTLE
Entity Type:Organization
Organization Name:POM POM CASTLE
Other - Org Name:CLEAN AND FREE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:BELINDA
Authorized Official - Middle Name:
Authorized Official - Last Name:BAKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:323-294-1576
Mailing Address - Street 1:14540 HAMLIN ST
Mailing Address - Street 2:SUITE D
Mailing Address - City:VAN NUYS
Mailing Address - State:CA
Mailing Address - Zip Code:91411-1626
Mailing Address - Country:US
Mailing Address - Phone:818-994-6876
Mailing Address - Fax:818-997-6878
Practice Address - Street 1:14540 HAMLIN ST
Practice Address - Street 2:SUITE D
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91411-1626
Practice Address - Country:US
Practice Address - Phone:818-994-6876
Practice Address - Fax:818-997-6878
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:POM POM CASTLE DBA CLEAN AND FREE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-01-19
Last Update Date:2012-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health