Provider Demographics
NPI:1336539642
Name:COMMUNITY LIFE DEV
Entity Type:Organization
Organization Name:COMMUNITY LIFE DEV
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:TARGET CASE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:YANTH
Authorized Official - Middle Name:
Authorized Official - Last Name:BARRETO
Authorized Official - Suffix:
Authorized Official - Credentials:BA
Authorized Official - Phone:847-707-9956
Mailing Address - Street 1:225 S SWOOPE AVE
Mailing Address - Street 2:
Mailing Address - City:MAITLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32751-5704
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:225 S SWOOPE AVE
Practice Address - Street 2:
Practice Address - City:MAITLAND
Practice Address - State:FL
Practice Address - Zip Code:32751-5704
Practice Address - Country:US
Practice Address - Phone:407-790-4927
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-26
Last Update Date:2015-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL593650750Medicaid