Provider Demographics
NPI:1366722852
Name:PROVIDENCE COMMUNITY SERVICES
Entity type:Organization
Organization Name:PROVIDENCE COMMUNITY SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INTERN
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTINA
Authorized Official - Middle Name:
Authorized Official - Last Name:SWANSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-518-1049
Mailing Address - Street 1:1219 RUTLAND RD
Mailing Address - Street 2:
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92660-4627
Mailing Address - Country:US
Mailing Address - Phone:909-518-1049
Mailing Address - Fax:
Practice Address - Street 1:3188 AIRWAY AVE
Practice Address - Street 2:UNIT F
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92626-4652
Practice Address - Country:US
Practice Address - Phone:714-689-1380
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-28
Last Update Date:2011-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health