Organization
CCIC LLC
Active
Other names
Country Care on Broadway
Organization subpart
No
Provider details
NPI number
Authorized official
MRS. TAMARA K O'DONNELL ACHA, MBA (OWNER)
(913) 680-0306
Entity
Organization
Contact information
Practice address
20379 EDWARDS DR, EASTON, KS 66020-8067
(913) 680-0306
Mailing address
20379 EDWARDS DR, EASTON, KS 66020-8067
(913) 680-0306
Taxonomy
Speciality
Code
Description
License number
State
314000000X
Skilled Nursing Facility
Primary
N052004
KS
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1041039901
—
KS
Enumeration date
10/07/2005
Last updated
08/22/2020
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