Provider Demographics
NPI:1093286395
Name:CCRC OF WEST DES MOINES, LLC
Entity Type:Organization
Organization Name:CCRC OF WEST DES MOINES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER BY CONTRACT
Authorized Official - Prefix:
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:
Authorized Official - Last Name:GULLEDGE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:913-890-4780
Mailing Address - Street 1:11827 W 112TH ST STE 103
Mailing Address - Street 2:
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66210-2718
Mailing Address - Country:US
Mailing Address - Phone:913-890-4780
Mailing Address - Fax:913-956-6564
Practice Address - Street 1:8950 COACHLIGHT DRIVE
Practice Address - Street 2:
Practice Address - City:WEST DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50266
Practice Address - Country:US
Practice Address - Phone:515-369-2100
Practice Address - Fax:913-956-6564
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-12-12
Last Update Date:2018-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility