Provider Demographics
NPI:1871622498
Name:OPTIMIST BOYS' HOME AND RANCH, INC.
Entity type:Organization
Organization Name:OPTIMIST BOYS' HOME AND RANCH, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:RUSHMORE
Authorized Official - Middle Name:
Authorized Official - Last Name:CERVANTES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:323-443-3101
Mailing Address - Street 1:6957 N FIGUEROA ST
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90042-1245
Mailing Address - Country:US
Mailing Address - Phone:323-443-3175
Mailing Address - Fax:323-344-5124
Practice Address - Street 1:520 W PALMDALE BLVD STE DEF&G
Practice Address - Street 2:
Practice Address - City:PALMDALE
Practice Address - State:CA
Practice Address - Zip Code:93551-4229
Practice Address - Country:US
Practice Address - Phone:323-443-3175
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-02
Last Update Date:2024-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral Health
No171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00781OtherMEDI-CAL PROVIDER