Provider Demographics
NPI:1922559756
Name:COMMUNITY LIVING ALLIANCE
Entity Type:Organization
Organization Name:COMMUNITY LIVING ALLIANCE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:TODD
Authorized Official - Middle Name:
Authorized Official - Last Name:COSTELLO
Authorized Official - Suffix:
Authorized Official - Credentials:MSN, MBA
Authorized Official - Phone:608-242-8335
Mailing Address - Street 1:PO BOX 8028
Mailing Address - Street 2:1414 MACARTHUR RD.
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53708-8028
Mailing Address - Country:US
Mailing Address - Phone:608-242-8335
Mailing Address - Fax:608-240-7060
Practice Address - Street 1:1414 MACARTHUR RD
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53714-1318
Practice Address - Country:US
Practice Address - Phone:608-242-8335
Practice Address - Fax:608-240-7060
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-17
Last Update Date:2016-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100012562Medicaid