Provider Demographics
NPI:1629353925
Name:WALLACE COUNTY COMMUNITY CARE CENTER, INC.
Entity Type:Organization
Organization Name:WALLACE COUNTY COMMUNITY CARE CENTER, INC.
Other - Org Name:WALLACE COUNTY COMMUNITY CARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BOARD CHAIRMAN
Authorized Official - Prefix:MR
Authorized Official - First Name:BRYAN
Authorized Official - Middle Name:F
Authorized Official - Last Name:PEARCE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:785-891-3587
Mailing Address - Street 1:608 N KENNEDY
Mailing Address - Street 2:
Mailing Address - City:SHARON SPRINGS
Mailing Address - State:KS
Mailing Address - Zip Code:67758-9701
Mailing Address - Country:US
Mailing Address - Phone:785-852-4244
Mailing Address - Fax:785-852-5279
Practice Address - Street 1:608 N KENNEDY
Practice Address - Street 2:
Practice Address - City:SHARON SPRINGS
Practice Address - State:KS
Practice Address - Zip Code:67758-9701
Practice Address - Country:US
Practice Address - Phone:785-852-4244
Practice Address - Fax:785-852-5279
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-18
Last Update Date:2013-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS175524Medicare Oscar/Certification