Healthcare Provider Details

I. General information

NPI: 1225241417
Provider Name (Legal Business Name): COLLEGE COMMUNITY SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/07/2007
Last Update Date: 06/03/2024
Certification Date: 06/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 N NORMA ST STE 125-133
RIDGECREST CA
93555-2575
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 760-499-7406
  • Fax: 760-499-7479
Mailing address:
  • Phone: 562-467-5440
  • Fax: 562-467-5553

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
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