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General NPI Number Information
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NPI Number | 1881682490
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Entity Type | Organization
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Legal Business Name | CCIC LLC
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Dates
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Enumeration Date | 10/07/2005
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 20379 EDWARDS DR
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City | EASTON
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State | KS
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Zip | 66020-8067
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Country | US
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Telephone | 913-680-0306
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Fax |
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Provider Business Mailing Address
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Address Line | 20379 EDWARDS DR
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City | EASTON
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State | KS
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Zip | 66020-8067
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Country | US
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Telephone | 913-680-0306
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | MRS. TAMARA K O'DONNELL
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Credential | ACHA, MBA
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Telephone | 913-680-0306
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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 | N052004
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License Number State | KS
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