MEDICARE: COMMUNITY RESIDENCE, INC.

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	029793	MO

General Provider Information

NPI Number	:	1669479150
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COMMUNITY RESIDENCE, INC.

Provider Business Mailing Address
First Line	:	312 SOLLEY DR
Second Line	:	REAR
City	:	BALLWIN
State	:	MO
Zip	:	63021-5248
Country	:	US
Telephone Number	:	636-394-3000
Fax Number	:	636-394-7713

Provider Business Practice Location Address
First Line	:	1425B S LANDRUM ST
Second Line	:
City	:	MOUNT VERNON
State	:	MO
Zip	:	65712-1912
Country	:	US
Telephone Number	:	417-466-3649
Fax Number	:	417-466-4909

Authorized Official
Title or Position	:	PRESIDENT
Name	:	JAMES GIARDINA
Credential	:
Telephone Number	:	636-394-3000

Provider Enumeration Date	:	06/30/2005
Last Update Date	:	10/30/2007

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Directions to “COMMUNITY RESIDENCE, INC. ” Practice Location

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