Organization
COMMUNITY CARE CENTER OF LICKING INC
Active
Other names
Licking Park Manor
Organization subpart
No
Provider details
NPI number
Authorized official
MR. JAMES J GIARDINA (PRESIDENT)
(636) 394-3000
Entity
Organization
Contact information
Practice address
209 HICKORY ST, LICKING, MO 65542-9847
(573) 674-2111
Mailing address
312 SOLLEY DR REAR, BALLWIN, MO 63021-5248
(636) 394-3000
Taxonomy
Speciality
Code
Description
License number
State
314000000X
Skilled Nursing Facility
Primary
035084
MO
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
101496800
—
MO
Enumeration date
03/29/2007
Last updated
01/10/2008
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