Basic Information
| Provider Information | |||||||||
| NPI: | 1851668842 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SOUTH COAST CHILDREN'S SOCIETY, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SOUTH COAST COMMUNITY SERVICES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 25910 ACERO STE 160 | ||||||||
| Address2: | |||||||||
| City: | MISSION VIEJO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926912777 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9099807000 | ||||||||
| FaxNumber: | 9095476552 | ||||||||
| Practice Location | |||||||||
| Address1: | 1425 W. FOOTHILL BLVD. | ||||||||
| Address2: | # 201 ,# 310 | ||||||||
| City: | UPLAND | ||||||||
| State: | CA | ||||||||
| PostalCode: | 91786 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9099806700 | ||||||||
| FaxNumber: | 9099806003 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/19/2011 | ||||||||
| LastUpdateDate: | 08/25/2022 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | DARLING | ||||||||
| AuthorizedOfficialFirstName: | KATHLEEN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | COO | ||||||||
| AuthorizedOfficialTelephone: | 9098384274 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SOUTH COAST CHILDREN'S SOCIETY | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 08/25/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 36FPTB | 05 | CA | MEDICAID |