Provider Demographics
NPI:1104245489
Name:DUNAMIS, INC. GROUP HOME
Entity type:Organization
Organization Name:DUNAMIS, INC. GROUP HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:ORLANDO
Authorized Official - Middle Name:
Authorized Official - Last Name:GILLAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:559-981-2143
Mailing Address - Street 1:1509 N MAROA AVE
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93728-1815
Mailing Address - Country:US
Mailing Address - Phone:559-441-1543
Mailing Address - Fax:
Practice Address - Street 1:1509 N MAROA AVE
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93728-1815
Practice Address - Country:US
Practice Address - Phone:559-441-1543
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DUNAMIS, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-04-15
Last Update Date:2014-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA100091AN324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1962637512OtherMEDI CAL