Provider Demographics
NPI:1669479150
Name:COMMUNITY RESIDENCE, INC.
Entity Type:Organization
Organization Name:COMMUNITY RESIDENCE, INC.
Other - Org Name:MT VERNON RESIDENTIAL CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:GIARDINA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:636-394-3000
Mailing Address - Street 1:312 SOLLEY DR
Mailing Address - Street 2:REAR
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:636-394-7713
Practice Address - Street 1:1425B S LANDRUM ST
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:MO
Practice Address - Zip Code:65712-1912
Practice Address - Country:US
Practice Address - Phone:417-466-3649
Practice Address - Fax:417-466-4909
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-30
Last Update Date:2007-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO029793311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home