Provider Demographics
NPI:1063469765
Name:C.M.C. EXTENDED CARE CENTER, INC.
Entity Type:Organization
Organization Name:C.M.C. EXTENDED CARE CENTER, INC.
Other - Org Name:LIFE CARE CENTER OF ST. LOUIS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ASSISTANT SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:CINDY
Authorized Official - Middle Name:S
Authorized Official - Last Name:CROSS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-473-5867
Mailing Address - Street 1:3001 KEITH ST NW
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:TN
Mailing Address - Zip Code:37312-3713
Mailing Address - Country:US
Mailing Address - Phone:423-473-5751
Mailing Address - Fax:423-339-8342
Practice Address - Street 1:3520 CHOUTEAU AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63103-2916
Practice Address - Country:US
Practice Address - Phone:314-771-2100
Practice Address - Fax:314-771-7667
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-28
Last Update Date:2021-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO31339314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
265610Medicare Oscar/Certification