Provider Demographics
NPI:1922382290
Name:PROVIDIAN RESIDENTIAL CARE SERVICES, INC.
Entity Type:Organization
Organization Name:PROVIDIAN RESIDENTIAL CARE SERVICES, INC.
Other - Org Name:FILLMORE CHRISTIAN GARDEN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ACCOUNTANT/OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CARMEN
Authorized Official - Middle Name:JAMILI
Authorized Official - Last Name:MILLY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:559-284-6183
Mailing Address - Street 1:4826 E FILLMORE AVE
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93727-3701
Mailing Address - Country:US
Mailing Address - Phone:559-284-6183
Mailing Address - Fax:559-452-1536
Practice Address - Street 1:4826 E FILLMORE AVE
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93727-3701
Practice Address - Country:US
Practice Address - Phone:559-284-6183
Practice Address - Fax:559-452-1536
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-05
Last Update Date:2012-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1072024783104A0625X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3104A0625XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Mental Illness