Provider Demographics
NPI:1235803081
Name:CC'S VILLA LLC
Entity Type:Organization
Organization Name:CC'S VILLA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHNNY
Authorized Official - Middle Name:
Authorized Official - Last Name:WELSH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:810-378-5550
Mailing Address - Street 1:41 W LORRAINE ST
Mailing Address - Street 2:
Mailing Address - City:PECK
Mailing Address - State:MI
Mailing Address - Zip Code:48466-9619
Mailing Address - Country:US
Mailing Address - Phone:810-378-5550
Mailing Address - Fax:
Practice Address - Street 1:41 W LORRAINE ST
Practice Address - Street 2:
Practice Address - City:PECK
Practice Address - State:MI
Practice Address - Zip Code:48466-9619
Practice Address - Country:US
Practice Address - Phone:810-378-5550
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-08-05
Last Update Date:2021-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities