Basic Information
| Provider Information | |||||||||
| NPI: | 1962824649 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PROVIDENCE COMMUNITY SERVICES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4281 KATELLA AVE | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | LOS ALAMITOS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 907203500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5624675577 | ||||||||
| FaxNumber: | 5624675553 | ||||||||
| Practice Location | |||||||||
| Address1: | 18000 STUDEBAKER RD | ||||||||
| Address2: | SUITE 700 | ||||||||
| City: | CERRITOS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 907032679 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5624675577 | ||||||||
| FaxNumber: | 5624675553 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/14/2014 | ||||||||
| LastUpdateDate: | 01/14/2014 | ||||||||
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| AuthorizedOfficialLastName: | MOLNAR | ||||||||
| AuthorizedOfficialFirstName: | MICHELLE | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR OF FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 5624675577 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | CA | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 0 | 05 | CA | MEDICAID |