Provider Demographics
NPI:1275530776
Name:COMMUNITY RESIDENCE, INC.
Entity Type:Organization
Organization Name:COMMUNITY RESIDENCE, INC.
Other - Org Name:LICKING RESIDENTIAL CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:GIARDINA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:636-394-3000
Mailing Address - Street 1:312 SOLLEY DR
Mailing Address - Street 2:REAR
Mailing Address - City:BALLWIN
Mailing Address - State:MO
Mailing Address - Zip Code:63021-5248
Mailing Address - Country:US
Mailing Address - Phone:636-394-3000
Mailing Address - Fax:636-394-7713
Practice Address - Street 1:225 W HIGHWAY 32
Practice Address - Street 2:
Practice Address - City:LICKING
Practice Address - State:MO
Practice Address - Zip Code:65542-9832
Practice Address - Country:US
Practice Address - Phone:573-674-2207
Practice Address - Fax:573-674-2239
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COMMUNITY RESIDENCE, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-06-30
Last Update Date:2008-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO030734311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO266178706Medicaid