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General NPI Number Information
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NPI Number | 1922382290
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Entity Type | Organization
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Legal Business Name | PROVIDIAN RESIDENTIAL CARE SERVICES, INC.
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Dates
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Enumeration Date | 10/05/2011
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Last Update Date | 02/07/2012
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Provider Practice Location Address
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Address Line | 4826 E FILLMORE AVE
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City | FRESNO
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State | CA
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Zip | 93727-3701
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Country | US
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Telephone | 559-284-6183
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Fax | 559-452-1536
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Provider Business Mailing Address
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Address Line | 4826 E FILLMORE AVE
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City | FRESNO
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State | CA
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Zip | 93727-3701
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Country | US
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Telephone | 559-284-6183
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Fax | 559-452-1536
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Authorized Official
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Title or Position | ACCOUNTANT/OWNER
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Name | MRS. CARMEN JAMILI MILLY
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Credential |
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Telephone | 559-284-6183
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 3104A0625X
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Taxonomy Name | Assisted Living Facility (Mental Illness)
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License Number | 107202478
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License Number State | CA
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