Provider Demographics
NPI:1598887804
Name:CARMEL COMMUNITY LIVING CORPORATION
Entity Type:Organization
Organization Name:CARMEL COMMUNITY LIVING CORPORATION
Other - Org Name:OVERTURE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:KELLY
Authorized Official - Suffix:
Authorized Official - Credentials:MSC
Authorized Official - Phone:720-660-1844
Mailing Address - Street 1:451 21ST AVE STE B
Mailing Address - Street 2:
Mailing Address - City:LONGMONT
Mailing Address - State:CO
Mailing Address - Zip Code:80501-1483
Mailing Address - Country:US
Mailing Address - Phone:303-444-0573
Mailing Address - Fax:720-563-0140
Practice Address - Street 1:11177 W 8TH AVE STE 220
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80215-5520
Practice Address - Country:US
Practice Address - Phone:720-496-2605
Practice Address - Fax:720-458-1665
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-06
Last Update Date:2022-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO251C00000X, 253Z00000X
320600000X, 385H00000X
CO04B477385HR2060X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385HR2060XRespite Care FacilityRespite CareRespite Care, Intellectual and/or Developmental Disabilities, Child
No251C00000XAgenciesDay Training, Developmentally Disabled Services
No253Z00000XAgenciesIn Home Supportive Care
No320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
No385H00000XRespite Care FacilityRespite Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO9000141122Medicaid