Healthcare Provider Details

I. General information

NPI: 1922903111
Provider Name (Legal Business Name): JCS-PINE VALLEY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/09/2026
Last Update Date: 10/09/2026
Certification Date: 10/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

28876 OLD HWY 80
PINE VALLEY CA
91962
US

IV. Provider business mailing address

PO BOX 1438
PINE VALLEY CA
91962-1438
US

V. Phone/Fax

Practice location:
  • Phone: 619-473-1300
  • Fax:
Mailing address:
  • Phone: 619-473-1300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251300000X
TaxonomyLocal Education Agency (LEA)
License Number
License Number StateNULL

VIII. Authorized Official

Name: CLAIRE ROUSH
Title or Position: DIRECTOR OF OPERATIONS
Credential:
Phone: 619-832-1220