MEDICARE: COLLEGE 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	251S00000X	Community/Behavioral Health Agency

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	30DD	OTHER	CA	MEDI-CAL PROVIDER NUMBER

General Provider Information

NPI Number	:	1841335692
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COLLEGE COMMUNITY SERVICES

Provider Business Mailing Address
First Line	:	8337 TELEGRAPH RD STE 300
Second Line	:
City	:	PICO RIVERA
State	:	CA
Zip	:	90660-4957
Country	:	US
Telephone Number	:	562-467-5440
Fax Number	:	562-467-5553

Provider Business Practice Location Address
First Line	:	631 S BROOKHURST ST STE 104
Second Line	:
City	:	ANAHEIM
State	:	CA
Zip	:	92804-3510
Country	:	US
Telephone Number	:	714-620-8131
Fax Number	:	714-620-8132

Authorized Official
Title or Position	:	DIRECTOR OF STATE OPERATIONS
Name	:	TRACY GINTER
Credential	:	MBA, CBCS
Telephone Number	:	657-465-9497

Provider Enumeration Date	:	02/20/2007
Last Update Date	:	08/14/2024

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