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General NPI Number Information
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NPI Number | 1295018745
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Entity Type | Organization
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Legal Business Name | CCLA 9 LLC
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Dates
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Enumeration Date | 09/21/2011
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Last Update Date | 09/21/2011
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Provider Practice Location Address
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Address Line | 7733 E JEFFERSON AVE
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City | DETROIT
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State | MI
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Zip | 48214-3707
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Country | US
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Telephone | 313-499-4100
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Fax | 313-499-4934
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Provider Business Mailing Address
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Address Line | PO BOX 250459
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City | FRANKLIN
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State | MI
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Zip | 48025-0459
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Country | US
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Telephone | 586-563-1500
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Fax | 568-563-1200
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Authorized Official
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Title or Position | DIRECTOR OF OPERATIONS
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Name | MR. TIM KAMEGO
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Credential |
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Telephone | 586-563-1500
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 314000000X
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Taxonomy Name | Skilled Nursing Facility
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License Number |
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License Number State |
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