Provider Demographics
NPI:1679172738
Name:FUNCTIONAL LIVING COMMUNITY SUPPORTS
Entity Type:Organization
Organization Name:FUNCTIONAL LIVING COMMUNITY SUPPORTS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:SAUNDRA
Authorized Official - Middle Name:J
Authorized Official - Last Name:LIGHT GIBBONS
Authorized Official - Suffix:
Authorized Official - Credentials:OTR/L
Authorized Official - Phone:216-367-9017
Mailing Address - Street 1:3695 GREEN RD UNIT 221048
Mailing Address - Street 2:
Mailing Address - City:BEACHWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:44122-7953
Mailing Address - Country:US
Mailing Address - Phone:216-367-9017
Mailing Address - Fax:
Practice Address - Street 1:14221 REDDINGTON AVE
Practice Address - Street 2:
Practice Address - City:MAPLE HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44137-3209
Practice Address - Country:US
Practice Address - Phone:216-659-1098
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-10-20
Last Update Date:2020-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health