Healthcare Provider Details

I. General information

NPI: 1568388502
Provider Name (Legal Business Name): COMMUNITY GUIDED LIVING 'CGL'
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/24/2026
Last Update Date: 06/24/2026
Certification Date: 06/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10779 SORA DR
WILLIS TX
77378-2258
US

IV. Provider business mailing address

10779 SORA DR
WILLIS TX
77378-2258
US

V. Phone/Fax

Practice location:
  • Phone: 951-229-6039
  • Fax:
Mailing address:
  • Phone: 951-229-6039
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3104A0625X
TaxonomyAssisted Living Facility (Mental Illness)
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code373H00000X
TaxonomyDay Training/Habilitation Specialist
License Number
License Number State

VIII. Authorized Official

Name: MS. SAN JUANITA ROUNTREE
Title or Position: PRESIDENT
Credential:
Phone: 951-229-6039