Basic Information
| Provider Information | |||||||||
| NPI: | 1275749673 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COMMUNITY ADVANTAGE, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9901 LINN STATION RD | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402233808 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8008660860 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4100 W 17TH ST | ||||||||
| Address2: | |||||||||
| City: | GREELEY | ||||||||
| State: | CO | ||||||||
| PostalCode: | 806343334 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9703300203 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/15/2007 | ||||||||
| LastUpdateDate: | 11/03/2016 | ||||||||
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| AuthorizedOfficialLastName: | PANK | ||||||||
| AuthorizedOfficialFirstName: | MARY | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | PARALEGAL | ||||||||
| AuthorizedOfficialTelephone: | 5024202666 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 343900000X | CO | N | Transportation Services | Non-emergency Medical Transport (VAN) | 320900000X | CO | Y | Residential Treatment Facilities | Community Based Residential Treatment, Mental Retardation and/or Developmental Disabilities |
ID Information
| ID | Type | State | Issuer | Description | 09147133 | 05 | CO | MEDICAID |