Provider Demographics
NPI:1093917098
Name:C-C BOARDING HOME
Entity Type:Organization
Organization Name:C-C BOARDING HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:TREASURER
Authorized Official - Prefix:MR
Authorized Official - First Name:RAMON
Authorized Official - Middle Name:
Authorized Official - Last Name:CASTILLO
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:719-635-7159
Mailing Address - Street 1:412 S HANCOCK AVE
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80903-3700
Mailing Address - Country:US
Mailing Address - Phone:719-635-7159
Mailing Address - Fax:719-392-5723
Practice Address - Street 1:412 S HANCOCK AVE
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80903-3700
Practice Address - Country:US
Practice Address - Phone:719-635-7159
Practice Address - Fax:719-392-5723
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COAL-00123104A0625X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3104A0625XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Mental Illness