Provider Demographics
NPI:1730381880
Name:SAN GABRIEL CHILDRENS CENTER INC
Entity type:Organization
Organization Name:SAN GABRIEL CHILDRENS CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:PORFIRIO
Authorized Official - Middle Name:
Authorized Official - Last Name:RINCON
Authorized Official - Suffix:
Authorized Official - Credentials:MA
Authorized Official - Phone:626-859-2089
Mailing Address - Street 1:4740 N GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91724-2005
Mailing Address - Country:US
Mailing Address - Phone:626-859-2089
Mailing Address - Fax:626-859-6537
Practice Address - Street 1:4740 N GRAND AVE
Practice Address - Street 2:
Practice Address - City:COVINA
Practice Address - State:CA
Practice Address - Zip Code:91724-2005
Practice Address - Country:US
Practice Address - Phone:626-859-2089
Practice Address - Fax:626-859-6537
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA7274A251S00000X
CA7274D251S00000X
CA322D00000X, 322D00000X, 322D00000X, 322D00000X, 322D00000X, 322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered251S00000XAgenciesCommunity/Behavioral Health
Not Answered322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0000056BJMedicaid