MEDICARE: CARISSA GROUP INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	320600000X	Intellectual and/or Developmental Disabilities Residential Treatment Facility

General Provider Information

NPI Number	:	1427592963
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CARISSA GROUP INC.

Provider Business Mailing Address
First Line	:	1048 STOWELL RANCH CIR
Second Line	:
City	:	CORONA
State	:	CA
Zip	:	92881-4739
Country	:	US
Telephone Number	:	909-815-7412
Fax Number	:	951-278-2957

Provider Business Practice Location Address
First Line	:	1048 STOWELL RANCH CIR
Second Line	:
City	:	CORONA
State	:	CA
Zip	:	92881-4739
Country	:	US
Telephone Number	:	909-815-7412
Fax Number	:	951-278-2957

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	SARBJIT MANN
Credential	:
Telephone Number	:	909-815-7412

Provider Enumeration Date	:	12/16/2016
Last Update Date	:	12/16/2016

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