Provider Demographics
NPI:1477975183
Name:KRC 1505 HEALTH CARE SERVICES LLC
Entity Type:Organization
Organization Name:KRC 1505 HEALTH CARE SERVICES LLC
Other - Org Name:CLARK CARE CENTER - ONE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:417-667-3900
Mailing Address - Street 1:1505 E ASHLAND ST
Mailing Address - Street 2:
Mailing Address - City:NEVADA
Mailing Address - State:MO
Mailing Address - Zip Code:64772-4025
Mailing Address - Country:US
Mailing Address - Phone:417-667-3900
Mailing Address - Fax:417-667-3923
Practice Address - Street 1:1505 EAST ASHLAND STREET
Practice Address - Street 2:
Practice Address - City:NEVADA
Practice Address - State:MO
Practice Address - Zip Code:64772
Practice Address - Country:US
Practice Address - Phone:417-667-3900
Practice Address - Fax:417-667-3923
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-15
Last Update Date:2014-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO041595310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility