Provider Demographics
NPI:1154207983
Name:CERTIFIED CARE ADULT FAMILY HOME LLC
Entity type:Organization
Organization Name:CERTIFIED CARE ADULT FAMILY HOME LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:
Authorized Official - Last Name:UDOMA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:863-512-1570
Mailing Address - Street 1:4111 W ROWAN AVE
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99205-7665
Mailing Address - Country:US
Mailing Address - Phone:863-512-1570
Mailing Address - Fax:
Practice Address - Street 1:4111 W ROWAN AVE
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99205-7665
Practice Address - Country:US
Practice Address - Phone:863-512-1570
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-08-15
Last Update Date:2025-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163W00000XNursing Service ProvidersRegistered NurseGroup - Multi-Specialty