Provider Demographics
NPI:1568469310
Name:CLARK'S MOUNTAIN MANAGEMENT, CORP
Entity Type:Organization
Organization Name:CLARK'S MOUNTAIN MANAGEMENT, CORP
Other - Org Name:CLAKR'S MOUNTAIN NURSING CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:VICE PRESIDENT - FINANCE
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:REIKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-471-1113
Mailing Address - Street 1:2100 BARNES ST
Mailing Address - Street 2:
Mailing Address - City:PIEDMONT
Mailing Address - State:MO
Mailing Address - Zip Code:63957-1008
Mailing Address - Country:US
Mailing Address - Phone:573-223-4297
Mailing Address - Fax:573-223-7121
Practice Address - Street 1:2100 BARNES ST
Practice Address - Street 2:
Practice Address - City:PIEDMONT
Practice Address - State:MO
Practice Address - Zip Code:63957-1008
Practice Address - Country:US
Practice Address - Phone:573-223-4297
Practice Address - Fax:573-223-7121
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-07
Last Update Date:2011-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO031284314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO101453504Medicaid
MO265416Medicare Oscar/Certification