MEDICARE: PROVIDENCE COMMUNITY SERVICES

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251B00000X	Case Management Agency

General Provider Information

NPI Number	:	1801920319
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PROVIDENCE COMMUNITY SERVICES

Provider Business Mailing Address
First Line	:	3240 OLIVE ST
Second Line	:	APARTMENT #50
City	:	LEMON GROVE
State	:	CA
Zip	:	91945-1768
Country	:	US
Telephone Number	:	619-248-3835
Fax Number	:

Provider Business Practice Location Address
First Line	:	3240 OLIVE ST
Second Line	:	APARTMENT #50
City	:	LEMON GROVE
State	:	CA
Zip	:	91945-1768
Country	:	US
Telephone Number	:	619-248-3835
Fax Number	:

Authorized Official
Title or Position	:	CASE MANAGER
Name	:	MR. JAMAL LEO ST.CYR
Credential	:	B.A.
Telephone Number	:	858-300-0460

Provider Enumeration Date	:	03/15/2007
Last Update Date	:	08/22/2020

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