MEDICARE: CKK RESIDENTIAL CARE LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	311ZA0620X	Adult Care Home Facility

General Provider Information

NPI Number	:	1508703430
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CKK RESIDENTIAL CARE LLC

Provider Business Mailing Address
First Line	:	3784 EDISON AVE
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89121-3407
Country	:	US
Telephone Number	:	702-782-7265
Fax Number	:

Provider Business Practice Location Address
First Line	:	3784 EDISON AVE
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89121-3407
Country	:	US
Telephone Number	:	702-782-7265
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DIRK BENEDICT MAYANDIA
Credential	:
Telephone Number	:	702-782-7265

Provider Enumeration Date	:	04/29/2026
Last Update Date	:	04/29/2026

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