MEDICARE: CLEARWATER RETIREMENT COMMUNITY 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	NO87016	KS
2	310400000X	Assisted Living Facility	NO87053	KS
3	311500000X	Alzheimer Center (Dementia Center)	BO87124	KS
4	311500000X	Alzheimer Center (Dementia Center)	BO87123	KS

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	:	1407819246
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CLEARWATER RETIREMENT COMMUNITY INC.

Provider Business Mailing Address
First Line	:	620 E WOOD ST
Second Line	:
City	:	CLEARWATER
State	:	KS
Zip	:	67026-9757
Country	:	US
Telephone Number	:	620-584-2271
Fax Number	:	620-584-4583

Provider Business Practice Location Address
First Line	:	620 E WOOD ST
Second Line	:
City	:	CLEARWATER
State	:	KS
Zip	:	67026-9757
Country	:	US
Telephone Number	:	620-584-2271
Fax Number	:	620-584-4583

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MRS. IZENA MONK
Credential	:
Telephone Number	:	620-584-2271

Provider Enumeration Date	:	04/11/2006
Last Update Date	:	09/11/2025

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