Healthcare Provider Details

I. General information

NPI: 1134520562
Provider Name (Legal Business Name): CITADEL COMMUNITY DEVELOPMENT CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/04/2014
Last Update Date: 04/21/2022
Certification Date: 04/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

937 VIA LATA SUITE 500
COLTON CA
92324-3958
US

IV. Provider business mailing address

568 N MOUNTAIN VIEW AVE
SAN BERNARDINO CA
92401-1231
US

V. Phone/Fax

Practice location:
  • Phone: 909-992-0929
  • Fax: 909-992-0932
Mailing address:
  • Phone: 909-992-0929
  • Fax: 909-992-0932

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number
License Number State

VIII. Authorized Official

Name: DONISE JACKSON
Title or Position: CHAIRMAN OF THE BOARD
Credential:
Phone: 909-992-0929