| Details | Last Recertification Date | Update | Recertification | 2/8/2024 1:07:17 PM | 2/28/2025 2:00:58 PM | 2/28/2025 2:00 PM |
| Details | Last Recertification Date | Update | Recertification | | 2/8/2024 1:07:17 PM | 2/8/2024 1:07 PM |
| Contacts | Primary Contact | Update | Recertification | Nguyen, Tiffany
Administrative Manager
Southland Integrated Services, Inc.
7146207075 | Nguyen, Tiffany
Program Director
Southland Integrated Services, Inc.
7146207075 | 2/8/2024 1:07 PM |
| Details | State | Update | | Approved | Active | 10/1/2023 12:01 AM |
| Medicaid Billing | NPI: State | Update | Reinstatement | | CA | 9/6/2023 3:20 PM |
| Contacts | Signed By | Update | Reinstatement | Nguyen, Tricia
CEO
7146403411 | Nguyen, Tricia
CEO
Southland Integrated Services, Inc.
7146207007 | 9/6/2023 3:20 PM |
| Contacts | Primary Contact | Update | Reinstatement | Do, Jackie
Clinic Manager
Southland Integrated Services, Inc.
7146207011 | Nguyen, Tiffany
Administrative Manager
Southland Integrated Services, Inc.
7146207075 | 9/6/2023 3:20 PM |
| Details | Last Recertification Date | Update | Reinstatement | 2/19/2020 7:46:26 AM | | 9/6/2023 3:20 PM |
| Dates | Last Date That 340B Drugs Purchased | Update | Reinstatement | 3/31/2021 12:00:00 AM | | 9/6/2023 3:20 PM |
| Details | Entity Name | Update | Reinstatement | Southland Integrated Services, Inc. | SOUTHLAND INTEGRATED SERVICES INC | 9/6/2023 3:20 PM |
| Dates | Participating Approval Date | Update | Reinstatement | 10/16/2015 12:00:00 AM | 9/6/2023 3:20:27 PM | 9/6/2023 3:20 PM |
| Details | State | Update | Reinstatement | Terminated | Approved | 9/6/2023 3:20 PM |
| Dates | Registration Date | Update | Reinstatement | 10/9/2015 12:00:00 AM | 7/6/2023 6:22:53 PM | 9/6/2023 3:20 PM |
| Dates | Signed By Date | Update | Reinstatement | 10/9/2015 12:00:00 AM | 7/6/2023 6:22:56 PM | 9/6/2023 3:20 PM |
| Dates | Start Date | Update | Reinstatement | 1/1/2016 12:00:00 AM | 10/1/2023 12:00:00 AM | 9/6/2023 3:20 PM |
| Terminations | Termination Date | Update | Reinstatement | 4/1/2021 12:00:00 AM | | 9/6/2023 3:20 PM |
| Terminations | Termination Effective Date | Update | Reinstatement | 3/31/2021 12:00:00 AM | | 9/6/2023 3:20 PM |
| Terminations | Termination Reason | Update | Reinstatement | Failure to recertify | | 9/6/2023 3:20 PM |
| Details | Comments Public | Insert | Reinstatement | | Participating from effective date: (01/1/2016) until terminated effective date: (04/1/2021); reinstatement effective date: (10/1/2023) | 7/12/2023 7:12 AM |
| Details | State | Update | | To Be Terminated | Terminated | 4/1/2021 12:01 AM |
| Dates | Last Date That 340B Drugs Purchased | Update | Recertification | | 3/31/2021 12:00:00 AM | 3/11/2021 6:54 AM |
| Details | State | Update | Recertification | Active | To Be Terminated | 3/11/2021 6:54 AM |
| Terminations | Termination Date | Update | Recertification | | 4/1/2021 12:00:00 AM | 3/11/2021 6:54 AM |
| Terminations | Termination Effective Date | Update | Recertification | | 3/31/2021 12:00:00 AM | 3/11/2021 6:54 AM |
| Terminations | Termination Reason | Update | Recertification | | Failure to recertify | 3/11/2021 6:54 AM |
| Addresses | Billing Address | Insert | Recertification | | Southland Integrated Services, Inc.
1618 West First Street
Santa Ana, CA 92703 | 2/19/2020 7:46 AM |
| Addresses | Main Address | Update | Recertification |
9862 Chapman Ave STE B
Garden Grove, CA 92841-2726 |
9862 Chapman Avenue
Garden Grove, CA 92841-2726 | 2/19/2020 7:46 AM |
| Details | Last Recertification Date | Update | Recertification | 2/11/2019 11:21:43 AM | 2/19/2020 7:46:26 AM | 2/19/2020 7:46 AM |
| Contacts | Primary Contact | Update | Change Request | Nguyen, Lana
Clinic Director
7146207010 | Do, Jackie
Clinic Manager
Southland Integrated Services, Inc.
7146207011 | 2/11/2019 12:42 PM |
| Details | Is Authorizing Official EHB Data | Update | Change Request | False | | 2/11/2019 12:42 PM |
| Details | Entity Subname | Update | Change Request | VNCOC- Southland Health Center | Southland Integrated Services, Inc. | 2/11/2019 12:42 PM |
| Details | Last Recertification Date | Update | Recertification | 2/28/2018 9:53:01 AM | 2/11/2019 11:21:43 AM | 2/11/2019 11:21 AM |
| Details | Last Recertification Date | Update | Recertification | 2/13/2017 12:00:00 AM | 2/28/2018 9:53:01 AM | 2/28/2018 9:53 AM |
| Contacts | Authorizing Official | Update | AO Change Request | Nguyen, Tricia
CEO
7146403411 | Nguyen, Tricia
CEO
Southland Integrated Services, Inc.
7146207007 | 2/20/2018 12:39 PM |
| Addresses | Main Address | Insert | | |
9862 Chapman Ave STE B
Garden Grove, CA 92841-2726 | 4/12/2017 11:10 AM |
| Contacts | Primary Contact | Insert | | | Nguyen, Lana
Clinic Director
7146207010 | 4/12/2017 11:10 AM |
| Contacts | Authorizing Official | Insert | | | Nguyen, Tricia
CEO
7146403411 | 4/12/2017 11:10 AM |
| Contacts | Signed By | Insert | | | Nguyen, Tricia
CEO
7146403411 | 4/12/2017 11:10 AM |
| Details | Entity Name | Update | | VIETNAMESE COMMUNITY OF ORANGE COUNTY | Southland Integrated Services, Inc. | 4/12/2017 11:09 AM |
| Details | Last Recertification Date | Update | | 2/29/2016 12:00:00 AM | 2/13/2017 12:00:00 AM | 2/16/2017 7:32 PM |
| Details | Last Recertification Date | Update | | | 2/29/2016 12:00:00 AM | 2/29/2016 5:46 PM |
| Dates | Participating Approval Date | Update | | | 10/16/2015 12:00:00 AM | 10/16/2015 1:57 PM |
| Details | State | Update | | Pending | Active | 10/16/2015 1:57 PM |
| Dates | Start Date | Update | | | 1/1/2016 12:00:00 AM | 10/16/2015 1:57 PM |
| Details | 340B ID | Update | | ONLINE_REG_54922 | CHC28371-00 | 10/14/2015 8:25 AM |
| Details | 340B ID | Update | | ONLINE_REG | ONLINE_REG_54922 | 10/9/2015 3:45 PM |
| Medicaid Billing | Medicaid: Is Primary | Insert | | | False | 10/9/2015 3:45 PM |
| Medicaid Billing | Medicaid: Number | Insert | | | FHC70783F | 10/9/2015 3:45 PM |
| Medicaid Billing | Medicaid: State | Insert | | | CA | 10/9/2015 3:45 PM |
| Medicaid Billing | NPI: Number | Insert | | | 1285708818 | 10/9/2015 3:45 PM |
| Details | Last Recertification Date | Insert | | | | 10/9/2015 3:45 PM |
| Details | Grant Number | Insert | | | H80CS28371 | 10/9/2015 3:45 PM |
| Details | 340B ID | Insert | | | ONLINE_REG | 10/9/2015 3:45 PM |
| Details | Is Authorizing Official EHB Data | Insert | | | False | 10/9/2015 3:45 PM |
| Dates | Last Date That 340B Drugs Purchased | Insert | | | | 10/9/2015 3:45 PM |
| Details | Medicare Provider Number | Insert | | | | 10/9/2015 3:45 PM |
| Details | Entity Name | Insert | | | VIETNAMESE COMMUNITY OF ORANGE COUNTY | 10/9/2015 3:45 PM |
| Details | Program Code | Insert | | | CH | 10/9/2015 3:45 PM |
| Details | Entity Subname | Insert | | | VNCOC- Southland Health Center | 10/9/2015 3:45 PM |
| Dates | Participating Approval Date | Insert | | | | 10/9/2015 3:45 PM |
| Details | State | Insert | | | Pending | 10/9/2015 3:45 PM |
| Dates | Registration Date | Insert | | | 10/9/2015 12:00:00 AM | 10/9/2015 3:45 PM |
| Dates | Signed By Date | Insert | | | 10/9/2015 12:00:00 AM | 10/9/2015 3:45 PM |
| Dates | Start Date | Insert | | | | 10/9/2015 3:45 PM |
| Terminations | Termination Comments | Insert | | | | 10/9/2015 3:45 PM |
| Terminations | Termination Date | Insert | | | | 10/9/2015 3:45 PM |
| Terminations | Termination Effective Date | Insert | | | | 10/9/2015 3:45 PM |
| Terminations | Termination Reason | Insert | | | | 10/9/2015 3:45 PM |