Provider Demographics
NPI:1275293375
Name:CC' ADULT FAMILY HOME
Entity Type:Organization
Organization Name:CC' ADULT FAMILY HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CONDESA
Authorized Official - Middle Name:DELMAR
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:262-505-4531
Mailing Address - Street 1:4557 N 30TH ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53209-6049
Mailing Address - Country:US
Mailing Address - Phone:414-639-7107
Mailing Address - Fax:
Practice Address - Street 1:4557 N 30TH ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53209-6049
Practice Address - Country:US
Practice Address - Phone:414-639-7107
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-12-30
Last Update Date:2021-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3104A0625XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Mental Illness