Provider Demographics
NPI:1649517764
Name:EGGLESTON YOUTH CENTERS, INC.
Entity type:Organization
Organization Name:EGGLESTON YOUTH CENTERS, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
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., SUITE E
Mailing Address - Street 2:
Mailing Address - City:IRWINDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91706
Mailing Address - Country:US
Mailing Address - Phone:626-627-6000
Mailing Address - Fax:626-480-7688
Practice Address - Street 1:13001 RAMONA BLVD STE E
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?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-09
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
324500000X
CA191500940253J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes253J00000XAgenciesFoster Care Agency
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation FacilityGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA7427OtherDRUG MEDI-CAL BILLING NO.
CA190716ANOtherDEPT OF ALCOHOL AND DRUG PROGRAMS
CA197427OtherMASTER PROVIDER FILE NO.