Provider Demographics
NPI:1790994796
Name:CAPITOL CITY RESIDENTIAL HEALTH CARE LLC
Entity Type:Organization
Organization Name:CAPITOL CITY RESIDENTIAL HEALTH CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:KELLEE
Authorized Official - Middle Name:R
Authorized Official - Last Name:DERICO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:317-632-1851
Mailing Address - Street 1:1608 E 10TH ST
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46201-1902
Mailing Address - Country:US
Mailing Address - Phone:317-632-1851
Mailing Address - Fax:866-480-7748
Practice Address - Street 1:1608 E 10TH ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46201-1902
Practice Address - Country:US
Practice Address - Phone:317-632-1851
Practice Address - Fax:866-480-7748
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN3104A0625X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3104A0625XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Mental Illness