Healthcare Provider Details

I. General information

NPI: 1467595140
Provider Name (Legal Business Name): PROVIDENCE COMMUNITY SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/14/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3240 OLIVE ST APT 50
LEMON GROVE CA
91945-1721
US

IV. Provider business mailing address

3240 OLIVE ST APT 50
LEMON GROVE CA
91945-1721
US

V. Phone/Fax

Practice location:
  • Phone: 619-248-3835
  • Fax:
Mailing address:
  • Phone: 619-248-3835
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State

VIII. Authorized Official

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