Community Care Center of Licking Inc

Primary specialty

Skilled Nursing FacilityTaxonomy code 314000000X

License

035084 Issued in MO

Legal business name

COMMUNITY CARE CENTER OF LICKING INC

Doing business as

Licking Park Manor

Practice address

209 Hickory St
Licking, MO 65542-9847

Phone

(573) 674-2111

NPI assigned

Mar 29, 2007

Last updated

Jan 10, 2008By the provider in NPPES

Organization subpart

No

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

Authorized official

Name

Mr. James J Giardina

Title

President

Phone

(636) 394-3000

Specialties & licenses 1

Addresses

Other identifiers 1

Other names 1

• Licking Park Manor Doing business as

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

{
    "created_epoch": "1175126400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1199923200000",
    "number": "1609996222",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "312 SOLLEY DR REAR",
            "city": "BALLWIN",
            "state": "MO",
            "postal_code": "630215248",
            "telephone_number": "636-394-3000"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "209 HICKORY ST",
            "city": "LICKING",
            "state": "MO",
            "postal_code": "655429847",
            "telephone_number": "573-674-2111"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "COMMUNITY CARE CENTER OF LICKING INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-03-29",
        "last_updated": "2008-01-10",
        "status": "A",
        "authorized_official_last_name": "GIARDINA",
        "authorized_official_first_name": "JAMES",
        "authorized_official_middle_name": "J",
        "authorized_official_title_or_position": "PRESIDENT",
        "authorized_official_telephone_number": "636-394-3000",
        "authorized_official_name_prefix": "Mr."
    },
    "taxonomies": [
        {
            "code": "314000000X",
            "taxonomy_group": "",
            "desc": "Skilled Nursing Facility",
            "state": "MO",
            "license": "035084",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "101496800",
            "state": "MO"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Licking Park Manor",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

• Austin R. Rust DMD PC
• Community Counseling Services of Missouri, L.L.C.
• Community Residence, Inc. (Licking Residential Care)
• Nancy Jane Cook, LPC
• Dogwood Investment Group LLC (Licking Residential Care)
• Douglas County Public Health Services Group, Inc. (Missouri Ozarks Community Health)

• Skilled Nursing Facility in Licking, MO
• Providers in Licking, MO by specialty
• Skilled Nursing Facility in Missouri

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jan 10, 2008; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.