Provider Demographics
NPI:1255754784
Name:PROVIDENCE COMMUNITY SERVICES
Entity type:Organization
Organization Name:PROVIDENCE COMMUNITY SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF FINANCE
Authorized Official - Prefix:
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:MOLNAR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:562-467-5577
Mailing Address - Street 1:4281 KATELLA AVE
Mailing Address - Street 2:SUITE 201
Mailing Address - City:LOS ALAMITOS
Mailing Address - State:CA
Mailing Address - Zip Code:90720-3500
Mailing Address - Country:US
Mailing Address - Phone:562-467-5577
Mailing Address - Fax:562-467-5553
Practice Address - Street 1:3890 11TH. STREET
Practice Address - Street 2:SUITE 118
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92501
Practice Address - Country:US
Practice Address - Phone:562-467-5577
Practice Address - Fax:562-467-5553
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-04
Last Update Date:2014-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00Medicaid