Provider Demographics
NPI:1376785105
Name:CCR HOME HEALTH CARE
Entity Type:Organization
Organization Name:CCR HOME HEALTH CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:SUE
Authorized Official - Last Name:PAYNE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:231-773-8496
Mailing Address - Street 1:4460 CLOVERVILLE RD
Mailing Address - Street 2:
Mailing Address - City:FRUITPORT
Mailing Address - State:MI
Mailing Address - Zip Code:49415-9714
Mailing Address - Country:US
Mailing Address - Phone:231-773-8496
Mailing Address - Fax:
Practice Address - Street 1:4460 CLOVERVILLE RD
Practice Address - Street 2:
Practice Address - City:FRUITPORT
Practice Address - State:MI
Practice Address - Zip Code:49415-9714
Practice Address - Country:US
Practice Address - Phone:231-773-8496
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-25
Last Update Date:2009-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251J00000XAgenciesNursing Care