1295944155 NPI number — SOUTH COUNTY SENIOR SERVICES

Table of content: (NPI 1295944155)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295944155 NPI number — SOUTH COUNTY SENIOR SERVICES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTH COUNTY SENIOR SERVICES
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
SOUTH COUNTY ADULT DAY SERVICES
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1295944155
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
24300 EL TORO RD
Provider Second Line Business Mailing Address:
BLDG. A
Provider Business Mailing Address City Name:
LAGUNA WOODS
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92637-2737
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
949-855-9444
Provider Business Mailing Address Fax Number:
949-855-4093

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
24300 EL TORO RD
Provider Second Line Business Practice Location Address:
BLDG. A
Provider Business Practice Location Address City Name:
LAGUNA WOODS
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92637-2737
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
949-855-9444
Provider Business Practice Location Address Fax Number:
949-855-4093
Provider Enumeration Date:
05/21/2007

Additional Information

Authorized Official

Authorized Official Last Name:
LIGHT
Authorized Official First Name:
JACK
Authorized Official Middle Name:
WALTER
Authorized Official Title or Position:
PROGRAM DIRECTOR
Authorized Official Telephone Number:
949-855-9444

Provider Taxonomy Codes

  • Taxonomy code: 261QA0600X , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: ADU70085G , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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