1336858075 NPI number — COMMUNITY & CHILD REHABILITATION SERVICE LLC

NPI Number: 1336858075
Health Care Provider/Practitioner: COMMUNITY & CHILD REHABILITATION SERVICE LLC

NPI Number : 1336858075 – JSON Data Format

                
{
  "Npi": {
    "NPI": "1336858075",
    "EntityType": "Organization",
    "ReplacementNPI": null,
    "EIN": null,
    "IsSoleProprietor": null,
    "IsOrgSubpart": "N",
    "ParentOrgLBN": null,
    "ParentOrgTIN": null,
    "OrgName": "COMMUNITY & CHILD REHABILITATION SERVICE LLC",
    "LastName": null,
    "FirstName": null,
    "MiddleName": null,
    "NamePrefix": null,
    "NameSuffix": null,
    "Credential": null,
    "OtherOrgName": null,
    "OtherOrgNameTypeCode": "6",
    "OtherLastName": null,
    "OtherFirstName": null,
    "OtherMiddleName": null,
    "OtherNamePrefix": null,
    "OtherNameSuffix": null,
    "OtherCredential": null,
    "OtherLastNameTypeCode": null,
    "FirstLineMailingAddress": "14233 W POINSETTIA DR",
    "SecondLineMailingAddress": null,
    "MailingAddressCityName": "SURPRISE",
    "MailingAddressStateName": "AZ",
    "MailingAddressPostalCode": "85379-4910",
    "MailingAddressCountryCode": "US",
    "MailingAddressTelephoneNumber": "623-455-1558",
    "MailingAddressFaxNumber": null,
    "FirstLinePracticeLocationAddress": "14233 W POINSETTIA DR",
    "SecondLinePracticeLocationAddress": null,
    "PracticeLocationAddressCityName": "SURPRISE",
    "PracticeLocationAddressStateName": "AZ",
    "PracticeLocationAddressPostalCode": "85379-4910",
    "PracticeLocationAddressCountryCode": "US",
    "PracticeLocationAddressTelephoneNumber": "623-455-1558",
    "PracticeLocationAddressFaxNumber": null,
    "EnumerationDate": "11/22/2022",
    "LastUpdateDate": "08/11/2025",
    "NPIDeactivationReasonCode": null,
    "NPIDeactivationReason": null,
    "NPIDeactivationDate": null,
    "NPIReactivationDate": null,
    "GenderCode": null,
    "Gender": null,
    "AuthorizedOfficialLastName": "ETUKUDOH",
    "AuthorizedOfficialFirstName": "AKANINYENE",
    "AuthorizedOfficialMiddleName": "JAMES",
    "AuthorizedOfficialTitle": "PROGRAM DIRECTOR",
    "AuthorizedOfficialNamePrefix": null,
    "AuthorizedOfficialNameSuffix": null,
    "AuthorizedOfficialCredential": "DNP",
    "AuthorizedOfficialTelephoneNumber": "623-455-1558",
    "Taxonomies": {
      "Taxonomy": [
        {
          "TaxonomyCode": "251C00000X",
          "TaxonomyName": "Developmentally Disabled Services Day Training Agency",
          "LicenseNumber": null,
          "LicenseNumberStateCode": "NULL",
          "PrimaryTaxonomySwitch": "N"
        },
        {
          "TaxonomyCode": "261QD1600X",
          "TaxonomyName": "Developmental Disabilities Clinic/Center",
          "LicenseNumber": null,
          "LicenseNumberStateCode": "NULL",
          "PrimaryTaxonomySwitch": "N"
        },
        {
          "TaxonomyCode": "261QH0100X",
          "TaxonomyName": "Health Service Clinic/Center",
          "LicenseNumber": null,
          "LicenseNumberStateCode": "NULL",
          "PrimaryTaxonomySwitch": "N"
        },
        {
          "TaxonomyCode": "276400000X",
          "TaxonomyName": "Substance Use Disorder Rehabilitation Hospital Unit",
          "LicenseNumber": null,
          "LicenseNumberStateCode": "NULL",
          "PrimaryTaxonomySwitch": "N"
        },
        {
          "TaxonomyCode": "302F00000X",
          "TaxonomyName": "Exclusive Provider Organization",
          "LicenseNumber": null,
          "LicenseNumberStateCode": "NULL",
          "PrimaryTaxonomySwitch": "N"
        },
        {
          "TaxonomyCode": "315P00000X",
          "TaxonomyName": "Intellectual Disabilities Intermediate Care Facility",
          "LicenseNumber": null,
          "LicenseNumberStateCode": "NULL",
          "PrimaryTaxonomySwitch": "N"
        },
        {
          "TaxonomyCode": "320600000X",
          "TaxonomyName": "Intellectual and/or Developmental Disabilities Residential Treatment Facility",
          "LicenseNumber": null,
          "LicenseNumberStateCode": "NULL",
          "PrimaryTaxonomySwitch": "N"
        },
        {
          "TaxonomyCode": "343900000X",
          "TaxonomyName": "Non-emergency Medical Transport (VAN)",
          "LicenseNumber": null,
          "LicenseNumberStateCode": "NULL",
          "PrimaryTaxonomySwitch": "N"
        },
        {
          "TaxonomyCode": "385HR2060X",
          "TaxonomyName": "Child Intellectual and/or Developmental Disabilities Respite Care",
          "LicenseNumber": null,
          "LicenseNumberStateCode": "NULL",
          "PrimaryTaxonomySwitch": "N"
        },
        {
          "TaxonomyCode": "163WR0400X",
          "TaxonomyName": "Rehabilitation Registered Nurse",
          "LicenseNumber": null,
          "LicenseNumberStateCode": "NULL",
          "PrimaryTaxonomySwitch": "N"
        },
        {
          "TaxonomyCode": "177F00000X",
          "TaxonomyName": "Lodging Provider",
          "LicenseNumber": null,
          "LicenseNumberStateCode": "NULL",
          "PrimaryTaxonomySwitch": "N"
        },
        {
          "TaxonomyCode": "252Y00000X",
          "TaxonomyName": "Early Intervention Provider Agency",
          "LicenseNumber": null,
          "LicenseNumberStateCode": "NULL",
          "PrimaryTaxonomySwitch": "N"
        },
        {
          "TaxonomyCode": "253Z00000X",
          "TaxonomyName": "In Home Supportive Care Agency",
          "LicenseNumber": null,
          "LicenseNumberStateCode": "NULL",
          "PrimaryTaxonomySwitch": "Y"
        }
      ]
    },
    "HealthcareProviderTaxonomyGroups": null
  }
}