Healthcare Provider Details

I. General information

NPI: 1720190788
Provider Name (Legal Business Name): CHRISTIAN CARE HOME
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 01/06/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 CHAMBERS RD
FERGUSON MO
63135-2133
US

IV. Provider business mailing address

800 CHAMBERS RD
FERGUSON MO
63135-2133
US

V. Phone/Fax

Practice location:
  • Phone: 314-522-8100
  • Fax: 314-522-2334
Mailing address:
  • Phone: 314-522-8100
  • Fax: 314-522-2334

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number030395
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code332BP3500X
TaxonomyParenteral & Enteral Nutrition Supplies (DME)
License Number4842620001
License Number StateMO

VIII. Authorized Official

Name: MS. CHARLOTTE FINK
Title or Position: ADMINISTRATOR
Credential:
Phone: 314-522-8100