Healthcare Provider Details

I. General information

NPI: 1720084759
Provider Name (Legal Business Name): COMMUNITY CARE CENTER OF MONMOUTH, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/23/2005
Last Update Date: 03/04/2021
Certification Date: 03/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

117 S I ST
MONMOUTH IL
61462-1544
US

IV. Provider business mailing address

437 SOVEREIGN CT
BALLWIN MO
63011-4432
US

V. Phone/Fax

Practice location:
  • Phone: 309-734-3811
  • Fax:
Mailing address:
  • Phone: 636-394-3000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number0027979
License Number StateIL

VIII. Authorized Official

Name: CHRISTINA M GIARDINA
Title or Position: PRESIDENT
Credential:
Phone: 636-394-3000