Healthcare Provider Details

I. General information

NPI: 1528426111
Provider Name (Legal Business Name): COMMUNITY WIDE CDS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/10/2016
Last Update Date: 02/10/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 LUNBECK AVE
GIDEON MO
63848-9276
US

IV. Provider business mailing address

104 LUNBECK AVE
GIDEON MO
63848-9276
US

V. Phone/Fax

Practice location:
  • Phone: 573-448-5520
  • Fax:
Mailing address:
  • Phone: 573-448-5520
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State

VIII. Authorized Official

Name: MR. TERRY DEAN DAVIS SR.
Title or Position: PRESIDENT
Credential:
Phone: 573-448-5520