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General NPI Number Information
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NPI Number | 1013904069
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Entity Type | Organization
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Legal Business Name | COUNTRY CLUB CARE CENTER OF WARRENSBURG, L.C.
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Dates
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Enumeration Date | 10/04/2005
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Last Update Date | 11/17/2011
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Provider Practice Location Address
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Address Line | 503 REGENT DR
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City | WARRENSBURG
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State | MO
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Zip | 64093-3231
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Country | US
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Telephone | 660-429-4444
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Fax | 660-429-4331
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Provider Business Mailing Address
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Address Line | 503 REGENT DR
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City | WARRENSBURG
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State | MO
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Zip | 64093-3231
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Country | US
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Telephone | 660-429-4444
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Fax | 660-429-4331
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Authorized Official
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Title or Position | VICE PRESIDENT OF OPERATIONS
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Name | MR. STEVE BUNCH
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Credential |
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Telephone | 660-429-4444
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 314000000X
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Taxonomy Name | Skilled Nursing Facility
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License Number | 035593
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License Number State | MO
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