Provider Demographics
NPI:1013200914
Name:CCRC OF GRIMES, LLC
Entity Type:Organization
Organization Name:CCRC OF GRIMES, LLC
Other - Org Name:KENNYBROOK VILLAGE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:GILBERT
Authorized Official - Middle Name:R
Authorized Official - Last Name:WOOD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:913-599-5705
Mailing Address - Street 1:11827 W 112TH ST
Mailing Address - Street 2:SUITE 103
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66210-2726
Mailing Address - Country:US
Mailing Address - Phone:913-890-4780
Mailing Address - Fax:913-956-6564
Practice Address - Street 1:200 SW BROOKSIDE DRIVE
Practice Address - Street 2:
Practice Address - City:GRIMES
Practice Address - State:IA
Practice Address - Zip Code:50111
Practice Address - Country:US
Practice Address - Phone:515-369-3900
Practice Address - Fax:515-369-3905
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-25
Last Update Date:2017-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA165605Medicare Oscar/Certification