Provider Demographics
NPI:1457963076
Name:OUTREACH NATION CLINICS
Entity Type:Organization
Organization Name:OUTREACH NATION CLINICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:KHALIDA
Authorized Official - Middle Name:
Authorized Official - Last Name:KHANUM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-825-8080
Mailing Address - Street 1:9375 ARCHIBALD AVE STE 107
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91730-5728
Mailing Address - Country:US
Mailing Address - Phone:909-825-8080
Mailing Address - Fax:909-360-1550
Practice Address - Street 1:9375 ARCHIBALD AVE STE 107
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-5728
Practice Address - Country:US
Practice Address - Phone:909-825-8080
Practice Address - Fax:909-360-1550
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-17
Last Update Date:2020-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty