MEDICARE: COMMUNITY CARE CTR OF SULLIVAN, INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	314000000X	Skilled Nursing Facility	033721	MO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1063419505
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COMMUNITY CARE CTR OF SULLIVAN, INC

Provider Business Mailing Address
First Line	:	437 SOVEREIGN CT
Second Line	:
City	:	BALLWIN
State	:	MO
Zip	:	63011-4432
Country	:	US
Telephone Number	:	636-394-3000
Fax Number	:

Provider Business Practice Location Address
First Line	:	940 MATTOX DR
Second Line	:
City	:	SULLIVAN
State	:	MO
Zip	:	63080-2364
Country	:	US
Telephone Number	:	573-468-7733
Fax Number	:	573-860-3168

Authorized Official
Title or Position	:	PRESIDENT
Name	:	CHRISTINA M GIARDINA
Credential	:
Telephone Number	:	636-394-3000

Provider Enumeration Date	:	06/30/2005
Last Update Date	:	03/04/2021

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