Healthcare Provider Details

I. General information

NPI: 1609996222
Provider Name (Legal Business Name): COMMUNITY CARE CENTER OF LICKING INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/29/2007
Last Update Date: 01/10/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

209 HICKORY ST
LICKING MO
65542-9847
US

IV. Provider business mailing address

312 SOLLEY DR REAR
BALLWIN MO
63021-5248
US

V. Phone/Fax

Practice location:
  • Phone: 573-674-2111
  • 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 Number035084
License Number StateMO

VIII. Authorized Official

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