Provider Demographics
NPI:1679849046
Name:TRADITIONAL COMMUNITY LIVING
Entity Type:Organization
Organization Name:TRADITIONAL COMMUNITY LIVING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:G
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:302-424-0907
Mailing Address - Street 1:8367 BRICK GRANARY RD
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:DE
Mailing Address - Zip Code:19960-3812
Mailing Address - Country:US
Mailing Address - Phone:302-424-0907
Mailing Address - Fax:
Practice Address - Street 1:8367 BRICK GRANARY ROAD
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:DE
Practice Address - Zip Code:19960
Practice Address - Country:US
Practice Address - Phone:302-424-0907
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-29
Last Update Date:2012-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DE20120227152320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities