# CCIC LLC

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- **Entity:** Organization
- **Status:** Active
- **Other names:** Country Care on Broadway
- **Organization subpart:** No

## Provider details

- **NPI number:** 1881682490
- **Authorized official:** MRS. TAMARA K O'DONNELL ACHA, MBA (OWNER)
- **Authorized official phone:** (913) 680-0306

## Contact information

- **Practice address:** 20379 EDWARDS DR, EASTON, KS 66020-8067
- **Practice address phone:** (913) 680-0306
- **Mailing address:** 20379 EDWARDS DR, EASTON, KS 66020-8067
- **Mailing address phone:** (913) 680-0306

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 314000000X | Skilled Nursing Facility | N052004 | KS | Yes |

## Other

- **Enumeration date:** 10/07/2005
- **Last updated:** 08/22/2020

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 05 | — | 1041039901 | — | KS |