Provider Demographics
NPI:1770709305
Name:COMMUNITY SENIORSERV, INC.
Entity type:Organization
Organization Name:COMMUNITY SENIORSERV, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:HOLLY
Authorized Official - Middle Name:
Authorized Official - Last Name:HAGLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:714-220-0224
Mailing Address - Street 1:1200 N KNOLLWOOD CIR
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92801-1309
Mailing Address - Country:US
Mailing Address - Phone:714-220-0224
Mailing Address - Fax:714-816-7397
Practice Address - Street 1:1158 N KNOLLWOOD CIR
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92801-1307
Practice Address - Country:US
Practice Address - Phone:714-220-2114
Practice Address - Fax:714-220-1406
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-18
Last Update Date:2015-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA060000244261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA010695OtherSCAN PROVIDER ID
CAADU70057FMedicaid