Provider Demographics
NPI:1831100932
Name:COMMUNITY LIVING CENTER - FRESNO
Entity type:Organization
Organization Name:COMMUNITY LIVING CENTER - FRESNO
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:LISA
Authorized Official - Middle Name:T
Authorized Official - Last Name:MCQUONE
Authorized Official - Suffix:
Authorized Official - Credentials:NHA
Authorized Official - Phone:559-459-1711
Mailing Address - Street 1:3003 N MARIPOSA
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93703
Mailing Address - Country:US
Mailing Address - Phone:559-459-1711
Mailing Address - Fax:559-459-1799
Practice Address - Street 1:3003 N MARIPOSA
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93703
Practice Address - Country:US
Practice Address - Phone:559-459-1711
Practice Address - Fax:559-459-1799
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZR05043FMedicaid
055043Medicare ID - Type Unspecified