Healthcare Provider Details

I. General information

NPI: 1649595513
Provider Name (Legal Business Name): C & R QUALITY LIVING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/02/2010
Last Update Date: 04/02/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1336 25TH AVE S STE 213
FARGO ND
58103-5202
US

IV. Provider business mailing address

1336 25TH AVE S STE 213
FARGO ND
58103-5202
US

V. Phone/Fax

Practice location:
  • Phone: 701-235-5744
  • Fax: 701-235-5569
Mailing address:
  • Phone: 701-235-5744
  • Fax: 701-235-5569

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number10067100
License Number StateND

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier39354
Identifier TypeMEDICAID
Identifier StateND
Identifier Issuer

VIII. Authorized Official

Name: MR. ROOSEVELT GAYLAH
Title or Position: PRESIDENT
Credential:
Phone: 701-235-5744