Provider Demographics
NPI:1437156965
Name:COMMUNITY CARE CENTER OF MASCOUTAH, INC.
Entity Type:Organization
Organization Name:COMMUNITY CARE CENTER OF MASCOUTAH, INC.
Other - Org Name:MAR-KA NURSING HOME
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTINA
Authorized Official - Middle Name:M
Authorized Official - Last Name:GIARDINA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:636-394-3000
Mailing Address - Street 1:437 SOVEREIGN CT
Mailing Address - Street 2:
Mailing Address - City:BALLWIN
Mailing Address - State:MO
Mailing Address - Zip Code:63011-4432
Mailing Address - Country:US
Mailing Address - Phone:636-394-3000
Mailing Address - Fax:
Practice Address - Street 1:201 S 10TH ST
Practice Address - Street 2:
Practice Address - City:MASCOUTAH
Practice Address - State:IL
Practice Address - Zip Code:62258-1736
Practice Address - Country:US
Practice Address - Phone:618-566-8000
Practice Address - Fax:618-566-2884
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-30
Last Update Date:2021-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0031740314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========002Medicaid
IL=========002Medicaid