Provider Demographics
NPI:1639684558
Name:COMMUNITY LIVING OPTIONS
Entity Type:Organization
Organization Name:COMMUNITY LIVING OPTIONS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR QA
Authorized Official - Prefix:
Authorized Official - First Name:LORINDA
Authorized Official - Middle Name:JUNE
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:269-343-6355
Mailing Address - Street 1:626 REED AVE
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49001-2971
Mailing Address - Country:US
Mailing Address - Phone:269-343-6355
Mailing Address - Fax:269-343-0054
Practice Address - Street 1:626 REED AVE
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49001-2971
Practice Address - Country:US
Practice Address - Phone:269-343-6355
Practice Address - Fax:269-343-0054
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-12-14
Last Update Date:2017-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIAS390073055253J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253J00000XAgenciesFoster Care Agency
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIAS390073055OtherOLD LOG TRAIL LICENSE NUMBER