Provider Demographics
NPI:1356481907
Name:COUNTRY CLUB CARE CENTER OF WARRENSBURG L C
Entity Type:Organization
Organization Name:COUNTRY CLUB CARE CENTER OF WARRENSBURG L C
Other - Org Name:COUNTRY CLUB CARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT OF OPERATIONS
Authorized Official - Prefix:MR
Authorized Official - First Name:STEVE
Authorized Official - Middle Name:
Authorized Official - Last Name:BUNCH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:660-429-4444
Mailing Address - Street 1:503 REGENT DR
Mailing Address - Street 2:
Mailing Address - City:WARRENSBURG
Mailing Address - State:MO
Mailing Address - Zip Code:64093-3231
Mailing Address - Country:US
Mailing Address - Phone:660-429-4444
Mailing Address - Fax:660-429-4331
Practice Address - Street 1:503 REGENT DR
Practice Address - Street 2:
Practice Address - City:WARRENSBURG
Practice Address - State:MO
Practice Address - Zip Code:64093-3231
Practice Address - Country:US
Practice Address - Phone:660-429-4444
Practice Address - Fax:660-429-4331
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-06
Last Update Date:2008-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO035594320700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320700000XResidential Treatment FacilitiesResidential Treatment Facility, Physical Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO268298007Medicaid