Provider Demographics
NPI:1285087445
Name:COMMUNITY RESIDENTIAL & RESPITE, LLC
Entity type:Organization
Organization Name:COMMUNITY RESIDENTIAL & RESPITE, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:BARBARA
Authorized Official - Middle Name:JH
Authorized Official - Last Name:YAEGER
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:719-546-6322
Mailing Address - Street 1:221 S UNION AVE
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81003-3490
Mailing Address - Country:US
Mailing Address - Phone:719-546-6322
Mailing Address - Fax:719-546-6154
Practice Address - Street 1:1640 E 4TH ST
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81001-4108
Practice Address - Country:US
Practice Address - Phone:719-545-2228
Practice Address - Fax:719-545-2229
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COMMUNITY RESIDENTIAL & RESPITE, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-07-22
Last Update Date:2016-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO90839056Medicaid