Provider Demographics
NPI:1023419439
Name:BOYS & GIRLS CLUBS OF GARDEN GROVE, INC.
Entity type:Organization
Organization Name:BOYS & GIRLS CLUBS OF GARDEN GROVE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:SURMANIAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:714-530-0430
Mailing Address - Street 1:10540 CHAPMAN AVE
Mailing Address - Street 2:
Mailing Address - City:GARDEN GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:92840-3101
Mailing Address - Country:US
Mailing Address - Phone:714-530-0430
Mailing Address - Fax:
Practice Address - Street 1:10602 CHAPMAN AVE
Practice Address - Street 2:
Practice Address - City:GARDEN GROVE
Practice Address - State:CA
Practice Address - Zip Code:92840-3146
Practice Address - Country:US
Practice Address - Phone:714-532-7940
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-05
Last Update Date:2016-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management