NPIMap

Organization Active NPI

CCRC of Grimes, LLC

Doing business as Kennybrook Village

  • Skilled Nursing Facility
  • Grimes, IA
National Provider Identifier
1013200914
Registry record updated Jan 26, 2017
On this page

Key facts

NPPES NPI Registry
Primary specialty
Skilled Nursing FacilityTaxonomy code 314000000X
Legal business name
CCRC OF GRIMES, LLC
Doing business as
Kennybrook Village
Practice address
200 SW Brookside Drive
Grimes, IA 50111
Phone
(515) 369-3900
Fax
(515) 369-3905
NPI assigned
May 25, 2011
Last updated
Jan 26, 2017By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jan 26, 2017

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Mr. Gilbert R Wood
Title
Managing Member
Phone
(913) 599-5705

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Skilled Nursing Facility 314000000X NU Primary

Addresses

Primary practice location

200 SW Brookside Drive
Grimes, IA 50111

Mailing address

11827 W 112TH St
Suite 103
Overland Park, KS 66210-2726
Phone (913) 890-4780

Other names 1

  • Kennybrook Village Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in IA

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20111207000874 IA Part A Provider - Skilled Nursing Facility 9830364538 Practice locations: Grimes, IA

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1013200914. Details of each certification follow.

Skilled nursing facility certification: CCN 165605

Legal name
CCRC OF GRIMES, LLC
Doing business as
KENNYBROOK VILLAGE
Certification status
Active
Provider type (POS)
Nursing home – SNF/NF dual certification
Participating since
Mar 23, 2012
Last certification
Jan 9, 2025
Beds
40
Ownership / control type
Individual
Multi-facility organization
Pivotal Health Care
Organization structure
LLCProprietary
Enrollment address
200 SW Brookside Dr
Grimes, IA 50111-2318
Nursing home name
KENNYBROOK VILLAGE
Affiliated entity
PIVOTAL HEALTH CARE

Care Compare: Nursing home

Medicare Care Compare
Listed as
Kennybrook VillageCCN 165605 · All quality measures
Overall star rating
3 of 5
Health inspections
3 of 5
Staffing
4 of 5
Quality measures
3 of 5
Type
Medicare and Medicaid
Ownership
For profit - Individual
Certified
Mar 23, 2012
Medicare certification status
ActiveFrom the Provider of Services file
Certified beds
4039.0 residents per day on average
Chain
Pivotal Health Care9 facilities in the chain

Processed by Care Compare on Aug 1, 2026.

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
16D2035960CCRC of Grimes, LLC200 SW Brookside Drive, Grimes, IA 50111Certificate of waiverJan 26, 2028
16D2217884CCRC of Grimes, LLC200 SW Brookside Dr, Grimes, IA 50111Certificate of waiverMar 23, 2027

National Provider Directory

National Provider Directory

Ownership & related parties

All disclosed owners & managing parties 23

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Poky Feeders Inc Organization, Scott City, KS Corporation, For-profit, Owned by another organization or individual Indirect Ownership Interest Mar 16, 2012 6.29%
Steven M Howard Individual Indirect Ownership Interest Mar 16, 2012 11.28%
Michael P Oconner Individual Operational/Managerial Control Oct 24, 2011
Adp of the SNF Oct 24, 2011
Wayne C Anderson Individual Indirect Ownership Interest Mar 16, 2012 6.4%
Pivotal Health Care LLC Organization, Overland Park, KS LLC, For-profit Operational/Managerial Control Mar 16, 2012 100%
Adp of the SNF Jun 18, 2025
Scott E Gulledge Individual Operational/Managerial Control Mar 16, 2012
Adp of the SNF Mar 16, 2012
Indirect Ownership Interest Mar 16, 2012 3.12%
Scenic Holdings LLC Organization, Overland Park, KS LLC, Holding company, For-profit, Owned by another organization or individual Direct Ownership Interest Dec 31, 2018 78.08%
Cadet Investment LLC Organization, Iowa Falls, IA LLC, For-profit, Owned by another organization or individual Indirect Ownership Interest Mar 16, 2012 10.87%
Jayce D Wilson Individual Operational/Managerial Control Apr 16, 2021
Adp of the SNF Apr 16, 2021
5 R Cattle, LLC Organization, Pagosa Springs, CO LLC, For-profit, Owned by another organization or individual Indirect Ownership Interest Mar 16, 2012 6.29%
Marlene a Anderson Individual Indirect Ownership Interest Mar 16, 2012 6.4%
WSG LLC Organization, Overland Park, KS LLC, For-profit, Owned by another organization or individual Indirect Ownership Interest Mar 16, 2012 16.44%
Organization, Overland Park, KS LLC, For-profit Adp of the SNF May 13, 2025
Lmray, LLC Organization, Pagosa Springs, CO LLC, For-profit, Owned by another organization or individual Indirect Ownership Interest Mar 16, 2012 6.29%
Gilbert R Wood Individual Operational/Managerial Control Mar 16, 2012
Indirect Ownership Interest Mar 16, 2012 2.24%
Travis S Gulledge Individual Operational/Managerial Control Jan 1, 2025
Adp of the SNF Jan 1, 2025
Indirect Ownership Interest Oct 1, 2021 0.89%
Summit Care, LLC Organization, Overland Park, KS LLC, For-profit Adp of the SNF Mar 16, 2012
3RK, LLC Organization, Pagosa Springs, CO LLC, For-profit, Owned by another organization or individual Indirect Ownership Interest Jan 1, 2021 6.28%
Jordan R Anderson Individual Operational/Managerial Control Jan 1, 2025
Indirect Ownership Interest Oct 1, 2021 1.79%
Scenic Development LLC Organization, Overland Park, KS LLC, For-profit Operational/Managerial Control Mar 16, 2012
Direct Ownership Interest Mar 16, 2012 21.92%
Organization, Urbandale, IA LLC, For-profit Adp of the SNF May 13, 2025
Iowa Physicians Clinic Medical Foundation Organization, West Des Moines, IA Non-profit Adp of the SNF Oct 24, 2011
Organization, Overland Park, KS LLC, For-profit Adp of the SNF May 13, 2025

Owners & managing parties with NPI records 4

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

Facilities with the same owner 9

Facilities that share an organizational owner with 5% or greater ownership or operational control.

Practitioners & affiliated clinicians

Affiliated clinicians 3

Clinicians who list this facility as an affiliation in Medicare Care Compare.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1306281600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1485388800000",
    "number": "1013200914",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "11827 W 112TH ST",
            "address_2": "SUITE 103",
            "city": "OVERLAND PARK",
            "state": "KS",
            "postal_code": "662102726",
            "telephone_number": "913-890-4780",
            "fax_number": "913-956-6564"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "200 SW BROOKSIDE DRIVE",
            "city": "GRIMES",
            "state": "IA",
            "postal_code": "50111",
            "telephone_number": "515-369-3900",
            "fax_number": "515-369-3905"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "CCRC OF GRIMES, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2011-05-25",
        "last_updated": "2017-01-26",
        "status": "A",
        "authorized_official_last_name": "WOOD",
        "authorized_official_first_name": "GILBERT",
        "authorized_official_middle_name": "R",
        "authorized_official_title_or_position": "MANAGING MEMBER",
        "authorized_official_telephone_number": "913-599-5705",
        "authorized_official_name_prefix": "Mr."
    },
    "taxonomies": [
        {
            "code": "314000000X",
            "taxonomy_group": "",
            "desc": "Skilled Nursing Facility",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Kennybrook Village",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Grimes, IA

Sources for this page

Verify at the official NPI Registry.