Provider Demographics
NPI:1336858075
Name:COMMUNITY & CHILD REHABILITATION SERVICES LLC
Entity Type:Organization
Organization Name:COMMUNITY & CHILD REHABILITATION SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER / STATUTORY AGENT
Authorized Official - Prefix:
Authorized Official - First Name:AKANINYENE
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:ETUKUDOH
Authorized Official - Suffix:
Authorized Official - Credentials:PMHNP
Authorized Official - Phone:623-455-1558
Mailing Address - Street 1:14233 W POINSETTIA DR
Mailing Address - Street 2:
Mailing Address - City:SURPRISE
Mailing Address - State:AZ
Mailing Address - Zip Code:85379-4910
Mailing Address - Country:US
Mailing Address - Phone:623-455-1558
Mailing Address - Fax:
Practice Address - Street 1:14233 W POINSETTIA DR
Practice Address - Street 2:
Practice Address - City:SURPRISE
Practice Address - State:AZ
Practice Address - Zip Code:85379-4910
Practice Address - Country:US
Practice Address - Phone:623-455-1558
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-11-22
Last Update Date:2022-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WR0400XNursing Service ProvidersRegistered NurseRehabilitationGroup - Multi-Specialty
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental HealthGroup - Multi-Specialty
No177F00000XOther Service ProvidersLodging
No251C00000XAgenciesDay Training, Developmentally Disabled Services
No252Y00000XAgenciesEarly Intervention Provider Agency
No253Z00000XAgenciesIn Home Supportive Care
No261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities
No261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
No276400000XHospital UnitsRehabilitation, Substance Use Disorder Unit
No302F00000XManaged Care OrganizationsExclusive Provider Organization
No320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
No343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
No385HR2060XRespite Care FacilityRespite CareRespite Care, Intellectual and/or Developmental Disabilities, ChildGroup - Multi-Specialty