Provider Demographics
NPI:1841502655
Name:MEDINA RESIDENTICAL CARE SERVICES
Entity type:Organization
Organization Name:MEDINA RESIDENTICAL CARE SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MYSTI
Authorized Official - Middle Name:
Authorized Official - Last Name:MEDINA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:559-392-7291
Mailing Address - Street 1:1568 N MILLBROOK AVE
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93703-4149
Mailing Address - Country:US
Mailing Address - Phone:559-392-7291
Mailing Address - Fax:559-840-1714
Practice Address - Street 1:1568 N MILLBROOK AVE
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93703-4149
Practice Address - Country:US
Practice Address - Phone:559-392-7291
Practice Address - Fax:559-840-1714
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-09
Last Update Date:2010-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251E00000X, 253Z00000X, 261QM0801X, 320800000X, 332U00000X, 343900000X, 347C00000X
CA107202360261QD1600X, 251C00000X
CA107203232320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
No251E00000XAgenciesHome Health
No253Z00000XAgenciesIn Home Supportive Care
No261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
No320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
No332U00000XSuppliersHome Delivered Meals
No343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
No347C00000XTransportation ServicesPrivate Vehicle