=====================================================
General NPI Number Information
=====================================================
NPI Number | 1518514850
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CZP COMMERCIAL PROJECTS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/21/2019
-----------------------------------------------------
Last Update Date | 08/21/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4414 PARK BREEZE DR
-----------------------------------------------------
City | FRESNO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77545-8605
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 832-620-9939
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4414 PARK BREEZE DR
-----------------------------------------------------
City | FRESNO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77545-8605
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 832-620-9939
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | CALVIN ZHAVONDA PHILLIPS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 832-620-9939
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3104A0625X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility (Mental Illness)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------