Provider Demographics
NPI:1316369192
Name:KRC 1495 HEALTH CARE SERVICES LLC
Entity Type:Organization
Organization Name:KRC 1495 HEALTH CARE SERVICES LLC
Other - Org Name:JOE CLARK RESIDENTIAL CARE HOME
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:MS
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:417-667-5000
Mailing Address - Street 1:PO BOX 246
Mailing Address - Street 2:
Mailing Address - City:NEVADA
Mailing Address - State:MO
Mailing Address - Zip Code:64772-0246
Mailing Address - Country:US
Mailing Address - Phone:417-667-5000
Mailing Address - Fax:
Practice Address - Street 1:1495 E ASHLAND ST
Practice Address - Street 2:
Practice Address - City:NEVADA
Practice Address - State:MO
Practice Address - Zip Code:64772-4016
Practice Address - Country:US
Practice Address - Phone:417-667-5000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-13
Last Update Date:2014-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO041597310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility