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? | Code | Type | Classification | Specialization | Group |
|---|---|---|---|---|---|
| Yes | 163WR0400X | Nursing Service Providers | Registered Nurse | Rehabilitation | Group - Multi-Specialty |
| No | 163WP0808X | Nursing Service Providers | Registered Nurse | Psychiatric/Mental Health | Group - Multi-Specialty |
| No | 177F00000X | Other Service Providers | Lodging | ||
| No | 251C00000X | Agencies | Day Training, Developmentally Disabled Services | ||
| No | 252Y00000X | Agencies | Early Intervention Provider Agency | ||
| No | 253Z00000X | Agencies | In Home Supportive Care | ||
| No | 261QD1600X | Ambulatory Health Care Facilities | Clinic/Center | Developmental Disabilities | |
| No | 261QH0100X | Ambulatory Health Care Facilities | Clinic/Center | Health Service | |
| No | 276400000X | Hospital Units | Rehabilitation, Substance Use Disorder Unit | ||
| No | 302F00000X | Managed Care Organizations | Exclusive Provider Organization | ||
| No | 320600000X | Residential Treatment Facilities | Residential Treatment Facility, Intellectual and/or Developmental Disabilities | ||
| No | 343900000X | Transportation Services | Non-emergency Medical Transport (VAN) | ||
| No | 385HR2060X | Respite Care Facility | Respite Care | Respite Care, Intellectual and/or Developmental Disabilities, Child | Group - Multi-Specialty |
