Healthcare Provider Details

I. General information

NPI: 1013200914
Provider Name (Legal Business Name): CCRC OF GRIMES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/25/2011
Last Update Date: 01/26/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 SW BROOKSIDE DRIVE
GRIMES IA
50111
US

IV. Provider business mailing address

11827 W 112TH ST SUITE 103
OVERLAND PARK KS
66210-2726
US

V. Phone/Fax

Practice location:
  • Phone: 515-369-3900
  • Fax: 515-369-3905
Mailing address:
  • Phone: 913-890-4780
  • Fax: 913-956-6564

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: MR. GILBERT R WOOD
Title or Position: MANAGING MEMBER
Credential:
Phone: 913-599-5705