Provider Demographics
NPI:1790030690
Name:CCLA9, LLC
Entity Type:Organization
Organization Name:CCLA9, LLC
Other - Org Name:RIVERVIEW HEALTH & REHAB CENTER VENT UNIT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS
Authorized Official - Prefix:MR
Authorized Official - First Name:TIM
Authorized Official - Middle Name:
Authorized Official - Last Name:KAMEGO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-342-1200
Mailing Address - Street 1:7733 E JEFFERSON AVE
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48214-3707
Mailing Address - Country:US
Mailing Address - Phone:313-432-1200
Mailing Address - Fax:313-432-1300
Practice Address - Street 1:7733 E JEFFERSON AVE
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48214-3707
Practice Address - Country:US
Practice Address - Phone:313-432-1200
Practice Address - Fax:313-432-1300
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-17
Last Update Date:2012-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility