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General NPI Number Information
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NPI Number | 1336858075
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Entity Type | Organization
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Legal Business Name | COMMUNITY & CHILD REHABILITATION SERVICE LLC
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Dates
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Enumeration Date | 11/22/2022
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Last Update Date | 08/11/2025
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Provider Practice Location Address
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Address Line | 14233 W POINSETTIA DR
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City | SURPRISE
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State | AZ
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Zip | 85379-4910
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Country | US
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Telephone | 623-455-1558
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Fax |
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Provider Business Mailing Address
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Address Line | 14233 W POINSETTIA DR
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City | SURPRISE
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State | AZ
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Zip | 85379-4910
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Country | US
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Telephone | 623-455-1558
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Fax |
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Authorized Official
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Title or Position | PROGRAM DIRECTOR
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Name | AKANINYENE JAMES ETUKUDOH
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Credential | DNP
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Telephone | 623-455-1558
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251C00000X
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Taxonomy Name | Developmentally Disabled Services Day Training Agency
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License Number |
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License Number State | NULL
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Taxonomy #2
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Taxonomy Code | 261QD1600X
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Taxonomy Name | Developmental Disabilities Clinic/Center
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License Number |
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License Number State | NULL
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Taxonomy #3
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Taxonomy Code | 261QH0100X
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Taxonomy Name | Health Service Clinic/Center
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License Number |
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License Number State | NULL
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Taxonomy #4
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Taxonomy Code | 276400000X
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Taxonomy Name | Substance Use Disorder Rehabilitation Hospital Unit
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License Number |
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License Number State | NULL
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Taxonomy #5
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Taxonomy Code | 302F00000X
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Taxonomy Name | Exclusive Provider Organization
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License Number |
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License Number State | NULL
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Taxonomy #6
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Taxonomy Code | 315P00000X
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Taxonomy Name | Intellectual Disabilities Intermediate Care Facility
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License Number |
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License Number State | NULL
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Taxonomy #7
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Taxonomy Code | 320600000X
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Taxonomy Name | Intellectual and/or Developmental Disabilities Residential Treatment Facility
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License Number |
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License Number State | NULL
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Taxonomy #8
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Taxonomy Code | 343900000X
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Taxonomy Name | Non-emergency Medical Transport (VAN)
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License Number |
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License Number State | NULL
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Taxonomy #9
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Taxonomy Code | 385HR2060X
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Taxonomy Name | Child Intellectual and/or Developmental Disabilities Respite Care
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License Number |
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License Number State | NULL
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Taxonomy #10
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Taxonomy Code | 163WR0400X
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Taxonomy Name | Rehabilitation Registered Nurse
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License Number |
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License Number State | NULL
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Taxonomy #11
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Taxonomy Code | 177F00000X
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Taxonomy Name | Lodging Provider
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License Number |
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License Number State | NULL
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Taxonomy #12
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Taxonomy Code | 252Y00000X
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Taxonomy Name | Early Intervention Provider Agency
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License Number |
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License Number State | NULL
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Taxonomy #13
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Taxonomy Code | 253Z00000X
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Taxonomy Name | In Home Supportive Care Agency
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License Number |
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License Number State | NULL
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