Provider Demographics
NPI:1346236791
Name:CARROLL HOUSE, INC.
Entity Type:Organization
Organization Name:CARROLL HOUSE, INC.
Other - Org Name:CARROLL HOUSE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:C
Authorized Official - Last Name:LINCOLN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-746-7100
Mailing Address - Street 1:306 GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:CARROLLTON
Mailing Address - State:MO
Mailing Address - Zip Code:64633-2203
Mailing Address - Country:US
Mailing Address - Phone:660-542-1599
Mailing Address - Fax:660-542-3241
Practice Address - Street 1:306 GRAND AVE
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:MO
Practice Address - Zip Code:64633-2203
Practice Address - Country:US
Practice Address - Phone:660-542-1599
Practice Address - Fax:660-542-3241
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-21
Last Update Date:2011-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO029457314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO106967904Medicaid
MO17206936OtherSTATE ID
MO17206936OtherSTATE ID