Provider Demographics
NPI:1982709150
Name:BOYS & GIRLS CLUB OF SANTA CRUZ COUNTY, INC.
Entity Type:Organization
Organization Name:BOYS & GIRLS CLUB OF SANTA CRUZ COUNTY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:VICKI
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:BARDEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:520-287-3733
Mailing Address - Street 1:590 N TYLER AVE
Mailing Address - Street 2:
Mailing Address - City:NOGALES
Mailing Address - State:AZ
Mailing Address - Zip Code:85621-2300
Mailing Address - Country:US
Mailing Address - Phone:520-287-3733
Mailing Address - Fax:520-287-3530
Practice Address - Street 1:590 N TYLER AVE
Practice Address - Street 2:
Practice Address - City:NOGALES
Practice Address - State:AZ
Practice Address - Zip Code:85621-2300
Practice Address - Country:US
Practice Address - Phone:520-287-3733
Practice Address - Fax:520-287-3530
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZCSA06ADHS0146251V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251V00000XAgenciesVoluntary or Charitable
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ761793OtherAHCCCS