Provider Demographics
NPI:1164617064
Name:WILCOX PROPERTIES OF COLUMBIA LLC
Entity Type:Organization
Organization Name:WILCOX PROPERTIES OF COLUMBIA LLC
Other - Org Name:CANDLELIGHT LODGE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:L
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-449-5287
Mailing Address - Street 1:1406 BUSINESS LOOP 70 W
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65202-1324
Mailing Address - Country:US
Mailing Address - Phone:573-449-5284
Mailing Address - Fax:
Practice Address - Street 1:1406 BUSINESS LOOP 70 W
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65202-1324
Practice Address - Country:US
Practice Address - Phone:573-449-5284
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-13
Last Update Date:2007-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO034174310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility