Provider Demographics
NPI:1609996222
Name:COMMUNITY CARE CENTER OF LICKING INC
Entity Type:Organization
Organization Name:COMMUNITY CARE CENTER OF LICKING INC
Other - Org Name:LICKING PARK MANOR
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:J
Authorized Official - Last Name:GIARDINA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:636-394-3000
Mailing Address - Street 1:312 SOLLEY DR REAR
Mailing Address - Street 2:
Mailing Address - City:BALLWIN
Mailing Address - State:MO
Mailing Address - Zip Code:63021-5248
Mailing Address - Country:US
Mailing Address - Phone:636-394-3000
Mailing Address - Fax:
Practice Address - Street 1:209 HICKORY ST
Practice Address - Street 2:
Practice Address - City:LICKING
Practice Address - State:MO
Practice Address - Zip Code:65542-9847
Practice Address - Country:US
Practice Address - Phone:573-674-2111
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-29
Last Update Date:2008-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO035084314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO101496800Medicaid
MO265632Medicare Oscar/Certification