Healthcare Provider Details

I. General information

NPI: 1780812982
Provider Name (Legal Business Name): PRELUDE 2 INDEPENDENT LIVING, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/25/2009
Last Update Date: 06/25/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5800 JAMESON CT SUITE #7
CARMICHAEL CA
95608-0880
US

IV. Provider business mailing address

5800 JAMESON CT SUITE #7
CARMICHAEL CA
95608-0880
US

V. Phone/Fax

Practice location:
  • Phone: 877-480-9373
  • Fax: 916-650-1105
Mailing address:
  • Phone: 877-480-9373
  • Fax: 916-650-1105

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number330201
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number330201
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number330201
License Number StateCA

VIII. Authorized Official

Name: MR. JOHN COREY RINGGOLD
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 877-480-9373