Provider Demographics
NPI:1790779924
Name:COMMUNITY CARE CENTER OF MARK TWAIN INC
Entity Type:Organization
Organization Name:COMMUNITY CARE CENTER OF MARK TWAIN INC
Other - Org Name:MARK TWAIN MANOR
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:CHRISTINA
Authorized Official - Middle Name:M
Authorized Official - Last Name:GIARDINA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:636-394-3000
Mailing Address - Street 1:437 SOVEREIGN CT
Mailing Address - Street 2:
Mailing Address - City:BALLWIN
Mailing Address - State:MO
Mailing Address - Zip Code:63011-4432
Mailing Address - Country:US
Mailing Address - Phone:636-394-3000
Mailing Address - Fax:
Practice Address - Street 1:11988 MARK TWAIN LN
Practice Address - Street 2:
Practice Address - City:BRIDGETON
Practice Address - State:MO
Practice Address - Zip Code:63044-2825
Practice Address - Country:US
Practice Address - Phone:314-291-8240
Practice Address - Fax:314-209-9426
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-02
Last Update Date:2021-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO030955314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO101497402Medicaid
MO265236Medicare Oscar/Certification
MO101497402Medicaid