Basic Information
Provider Information | |||||||||
NPI: | 1033321120 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SOUTH COAST CHILDREN'S SOCIETY, INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | SOUTH COAST COMMUNITY SERVICES | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 25910 ACERO STE 160 | ||||||||
Address2: |   | ||||||||
City: | MISSION VIEJO | ||||||||
State: | CA | ||||||||
PostalCode: | 926912777 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9099807000 | ||||||||
FaxNumber: | 9095476552 | ||||||||
Practice Location | |||||||||
Address1: | 9500 HAVEN AVE UNIT 100-175 | ||||||||
Address2: |   | ||||||||
City: | RANCHO CUCAMONGA | ||||||||
State: | CA | ||||||||
PostalCode: | 917305807 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9099806700 | ||||||||
FaxNumber: | 9099806003 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/03/2007 | ||||||||
LastUpdateDate: | 09/01/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | DARLING | ||||||||
AuthorizedOfficialFirstName: | KATHLEEN | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | COO | ||||||||
AuthorizedOfficialTelephone: | 9098384274 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MRS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 09/01/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X |   |   | Y |   | Agencies | Community/Behavioral Health |   |
ID Information
ID | Type | State | Issuer | Description | 36DB | 05 | CA |   | MEDICAID |