Healthcare Provider Details

I. General information

NPI: 1013904069
Provider Name (Legal Business Name): COUNTRY CLUB CARE CENTER OF WARRENSBURG, L.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/04/2005
Last Update Date: 11/17/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

503 REGENT DR
WARRENSBURG MO
64093-3231
US

IV. Provider business mailing address

503 REGENT DR
WARRENSBURG MO
64093-3231
US

V. Phone/Fax

Practice location:
  • Phone: 660-429-4444
  • Fax: 660-429-4331
Mailing address:
  • Phone: 660-429-4444
  • Fax: 660-429-4331

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number035593
License Number StateMO

VIII. Authorized Official

Name: MR. STEVE BUNCH
Title or Position: VICE PRESIDENT OF OPERATIONS
Credential:
Phone: 660-429-4444