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General NPI Number Information
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NPI Number | 1477550911
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Entity Type | Organization
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Legal Business Name | COMMUNITY CARE CENTER OF LOUISIANA, INC
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Dates
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Enumeration Date | 06/30/2005
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Last Update Date | 03/04/2021
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Provider Practice Location Address
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Address Line | 2407 KENTUCKY STREET
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City | LOUISIANA
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State | MO
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Zip | 63353-2503
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Country | US
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Telephone | 573-754-5456
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Fax | 573-754-6624
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Provider Business Mailing Address
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Address Line | 437 SOVEREIGN CT
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City | BALLWIN
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State | MO
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Zip | 63011-4432
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Country | US
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Telephone | 366-394-3000
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | CHRISTINA M GIARDINA
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Credential |
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Telephone | 636-394-3000
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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 | 033696
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License Number State | MO
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