Provider Demographics
NPI:1093521908
Name:COMMUNITY LIFE SUPPORT,INC
Entity type:Organization
Organization Name:COMMUNITY LIFE SUPPORT,INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:YADIRA
Authorized Official - Middle Name:I
Authorized Official - Last Name:MUNOZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-505-7518
Mailing Address - Street 1:486 FISHERMAN ST
Mailing Address - Street 2:
Mailing Address - City:OPA LOCKA
Mailing Address - State:FL
Mailing Address - Zip Code:33054-3818
Mailing Address - Country:US
Mailing Address - Phone:305-688-5456
Mailing Address - Fax:305-688-1661
Practice Address - Street 1:486 FISHERMAN ST
Practice Address - Street 2:
Practice Address - City:OPA LOCKA
Practice Address - State:FL
Practice Address - Zip Code:33054-3818
Practice Address - Country:US
Practice Address - Phone:305-688-5456
Practice Address - Fax:305-688-1661
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-12-05
Last Update Date:2024-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center