Healthcare Provider Details

I. General information

NPI: 1750831889
Provider Name (Legal Business Name): COLLEGE COMMUNITY SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/13/2016
Last Update Date: 06/03/2024
Certification Date: 06/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 S TUSTIN ST BUILDING #C
ORANGE CA
92866-2550
US

IV. Provider business mailing address

8337 TELEGRAPH RD STE 300
PICO RIVERA CA
90660-4957
US

V. Phone/Fax

Practice location:
  • Phone: 714-361-4860
  • Fax:
Mailing address:
  • Phone: 562-467-5440
  • Fax: 562-467-5553

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: TRACY GINTER
Title or Position: DIRECTOR OF STATE OPERATIONS
Credential: MBA, CBCS
Phone: 657-465-9497