Provider Demographics
NPI:1942446927
Name:COMMUNITY ACTION AGENCY
Entity type:Organization
Organization Name:COMMUNITY ACTION AGENCY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:TOBY
Authorized Official - Middle Name:
Authorized Official - Last Name:BERRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:517-539-8311
Mailing Address - Street 1:400 W SOUTH ST
Mailing Address - Street 2:
Mailing Address - City:ADRIAN
Mailing Address - State:MI
Mailing Address - Zip Code:49221-3825
Mailing Address - Country:US
Mailing Address - Phone:517-263-7861
Mailing Address - Fax:517-263-6531
Practice Address - Street 1:400 W SOUTH ST
Practice Address - Street 2:
Practice Address - City:ADRIAN
Practice Address - State:MI
Practice Address - Zip Code:49221-3825
Practice Address - Country:US
Practice Address - Phone:517-263-7861
Practice Address - Fax:517-263-6531
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WOMEN INFANTS CHILDREN
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-12-23
Last Update Date:2024-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4703062118305S00000X, 133NN1002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, EducationGroup - Single Specialty
No305S00000XManaged Care OrganizationsPoint of ServiceGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI=========Medicaid