Healthcare Provider Details

I. General information

NPI: 1063469765
Provider Name (Legal Business Name): C.M.C. EXTENDED CARE CENTER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/28/2006
Last Update Date: 09/15/2021
Certification Date: 09/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3520 CHOUTEAU AVE
SAINT LOUIS MO
63103-2916
US

IV. Provider business mailing address

3001 KEITH ST NW
CLEVELAND TN
37312-3713
US

V. Phone/Fax

Practice location:
  • Phone: 314-771-2100
  • Fax: 314-771-7667
Mailing address:
  • Phone: 423-473-5751
  • Fax: 423-339-8342

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number31339
License Number StateMO

VIII. Authorized Official

Name: CINDY S CROSS
Title or Position: ASSISTANT SECRETARY
Credential:
Phone: 423-473-5867