MEDICARE: COMMUNITY LIVING CONCEPTS, INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number State
1	320900000X	Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
2	251S00000X	Community/Behavioral Health Agency
3	320900000X	Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility	TX

General Provider Information

NPI Number	:	1316002439
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COMMUNITY LIVING CONCEPTS, INC

Provider Business Mailing Address
First Line	:	110 EAST WALNUT ST
Second Line	:
City	:	KEENE
State	:	TX
Zip	:	76059
Country	:	US
Telephone Number	:	817-558-9559
Fax Number	:	817-928-1676

Provider Business Practice Location Address
First Line	:	110 EAST WALNUT ST
Second Line	:
City	:	KEENE
State	:	TX
Zip	:	76059
Country	:	US
Telephone Number	:	817-558-9559
Fax Number	:	817-928-1676

Authorized Official
Title or Position	:	CEO
Name	:	KYLE HANNAH
Credential	:
Telephone Number	:	817-558-9559

Provider Enumeration Date	:	12/27/2006
Last Update Date	:	10/03/2023

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