Basic Information
| Provider Information | |||||||||
| NPI: | 1104154533 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COLLEGE COMMUNITY SERVICES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8337 TELEGRAPH RD STE 115 | ||||||||
| Address2: | |||||||||
| City: | PICO RIVERA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 906604940 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5624675440 | ||||||||
| FaxNumber: | 5624675553 | ||||||||
| Practice Location | |||||||||
| Address1: | 2717 NUGGET AVENUE | ||||||||
| Address2: | |||||||||
| City: | LAKE ISABELLA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 93240 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7603793412 | ||||||||
| FaxNumber: | 7603795332 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/23/2009 | ||||||||
| LastUpdateDate: | 08/09/2021 | ||||||||
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| AuthorizedOfficialLastName: | GINTER | ||||||||
| AuthorizedOfficialFirstName: | TRACY | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR OF STATE OPERATIONS | ||||||||
| AuthorizedOfficialTelephone: | 7145036880 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | CBCS | ||||||||
| NPICertificationDate: | 08/09/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | Y | Agencies | Community/Behavioral Health |
No ID Information.