MEDICARE: CLARK COUNTY NURSING HOME

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	035239	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
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1194718908
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CLARK COUNTY NURSING HOME

Provider Business Mailing Address
First Line	:	1260 N JOHNSON ST
Second Line	:
City	:	KAHOKA
State	:	MO
Zip	:	63445-1100
Country	:	US
Telephone Number	:	660-727-3303
Fax Number	:	660-727-3736

Provider Business Practice Location Address
First Line	:	1260 N JOHNSON ST
Second Line	:
City	:	KAHOKA
State	:	MO
Zip	:	63445-1100
Country	:	US
Telephone Number	:	660-727-3303
Fax Number	:	660-727-3736

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MS. TAMMY MCDANIEL-RAMSEY
Credential	:	R.N.
Telephone Number	:	660-727-3303

Provider Enumeration Date	:	08/26/2005
Last Update Date	:	07/31/2009

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Directions to “CLARK COUNTY NURSING HOME ” Practice Location

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