1275530776 NPI number — COMMUNITY RESIDENCE, INC.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275530776 NPI number — COMMUNITY RESIDENCE, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COMMUNITY RESIDENCE, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
LICKING RESIDENTIAL CARE
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1275530776
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/13/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
312 SOLLEY DR
Provider Second Line Business Mailing Address:
REAR
Provider Business Mailing Address City Name:
BALLWIN
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63021-5248
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
636-394-3000
Provider Business Mailing Address Fax Number:
636-394-7713

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
225 W HIGHWAY 32
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LICKING
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
65542-9832
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
573-674-2207
Provider Business Practice Location Address Fax Number:
573-674-2239
Provider Enumeration Date:
06/30/2005

Additional Information

Authorized Official

Authorized Official Last Name:
GIARDINA
Authorized Official First Name:
JAMES
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
636-394-3000

Provider Taxonomy Codes

  • Taxonomy code: 311ZA0620X , with the licence number:  030734 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 266178706 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".




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