Provider Demographics
NPI:1972040194
Name:EGGLESTON YOUTH CENTERS, INC.
Entity Type:Organization
Organization Name:EGGLESTON YOUTH CENTERS, INC.
Other - Org Name:EGGLESTON BHS - WEST COVINA
Other - Org Type:Other Name
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 E
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:626-869-0280
Practice Address - Street 1:1526 S ST MALO ST
Practice Address - Street 2:
Practice Address - City:WEST COVINA
Practice Address - State:CA
Practice Address - Zip Code:91790-4836
Practice Address - Country:US
Practice Address - Phone:626-480-8107
Practice Address - Fax:626-869-0280
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EGGLESTON YOUTH CENTERS, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-01-25
Last Update Date:2018-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QM0855X
CA197806374322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health