Provider Demographics
NPI:1023564333
Name:SPECIAL CARE SUPPORTED LIVING SERVICES, LLC
Entity Type:Organization
Organization Name:SPECIAL CARE SUPPORTED LIVING SERVICES, LLC
Other - Org Name:SPECIAL CARE SUPPORTED LIVING SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING MEMBER/DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:DEBORAH
Authorized Official - Middle Name:L
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:707-580-7849
Mailing Address - Street 1:1015 LOTZ WAY
Mailing Address - Street 2:
Mailing Address - City:SUISUN CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94585-2654
Mailing Address - Country:US
Mailing Address - Phone:707-580-7849
Mailing Address - Fax:
Practice Address - Street 1:1015 LOTZ WAY
Practice Address - Street 2:
Practice Address - City:SUISUN CITY
Practice Address - State:CA
Practice Address - Zip Code:94585-2654
Practice Address - Country:US
Practice Address - Phone:707-580-7849
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-27
Last Update Date:2016-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251B00000X, 251C00000X
CAA4785151251J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
No251B00000XAgenciesCase Management
No251J00000XAgenciesNursing Care