1710104344 NPI number — COMMUNITY SENIORSERV, INC.

Table of content: (NPI 1710104344)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710104344 NPI number — COMMUNITY SENIORSERV, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COMMUNITY SENIORSERV, INC.
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:
SANTA ANA VIP ADULT DAY HEALTH CARE
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:
1710104344
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/24/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1200 N KNOLLWOOD CIR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ANAHEIM
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92801-1309
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
714-220-0224
Provider Business Mailing Address Fax Number:
714-816-7397

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1101 S GRAND AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SANTA ANA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92705-4100
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
714-558-1216
Provider Business Practice Location Address Fax Number:
714-564-0386
Provider Enumeration Date:
04/18/2007

Additional Information

Authorized Official

Authorized Official Last Name:
HAGLER
Authorized Official First Name:
HOLLY
Authorized Official Middle Name:
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
714-220-0224

Provider Taxonomy Codes

  • Taxonomy code: 261QH0100X , with the licence number:  060000064 , 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: 013679 . This is a "SCAN PROVIDER ID" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: ADU70080F , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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