Healthcare Provider Details

I. General information

NPI: 1033116520
Provider Name (Legal Business Name): COMMUNITY RESIDENCE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/30/2005
Last Update Date: 10/30/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 FIR RD
CARL JUNCTION MO
64834-9222
US

IV. Provider business mailing address

312 SOLLEY DR REAR
BALLWIN MO
63021-5248
US

V. Phone/Fax

Practice location:
  • Phone: 417-782-5659
  • Fax: 417-659-8880
Mailing address:
  • Phone: 636-394-3000
  • Fax: 636-394-7713

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License Number029987
License Number StateMO

VIII. Authorized Official

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