Provider Demographics
NPI:1649595513
Name:C & R QUALITY LIVING LLC
Entity Type:Organization
Organization Name:C & R QUALITY LIVING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:ROOSEVELT
Authorized Official - Middle Name:
Authorized Official - Last Name:GAYLAH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:701-235-5744
Mailing Address - Street 1:1336 25TH AVE S STE 213
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-5202
Mailing Address - Country:US
Mailing Address - Phone:701-235-5744
Mailing Address - Fax:701-235-5569
Practice Address - Street 1:1336 25TH AVE S STE 213
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-5202
Practice Address - Country:US
Practice Address - Phone:701-235-5744
Practice Address - Fax:701-235-5569
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-02
Last Update Date:2010-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND10067100251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND39354Medicaid