Provider Demographics
NPI:1295944155
Name:SOUTH COUNTY SENIOR SERVICES
Entity type:Organization
Organization Name:SOUTH COUNTY SENIOR SERVICES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PROGRAM DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JACK
Authorized Official - Middle Name:WALTER
Authorized Official - Last Name:LIGHT
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:949-855-9444
Mailing Address - Street 1:24300 EL TORO RD
Mailing Address - Street 2:BLDG. A
Mailing Address - City:LAGUNA WOODS
Mailing Address - State:CA
Mailing Address - Zip Code:92637-2737
Mailing Address - Country:US
Mailing Address - Phone:949-855-9444
Mailing Address - Fax:949-855-4093
Practice Address - Street 1:24300 EL TORO RD
Practice Address - Street 2:BLDG. A
Practice Address - City:LAGUNA WOODS
Practice Address - State:CA
Practice Address - Zip Code:92637-2737
Practice Address - Country:US
Practice Address - Phone:949-855-9444
Practice Address - Fax:949-855-4093
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA261QA0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAADU70085GMedicaid