Basic Information
| Provider Information | |||||||||
| NPI: | 1477550911 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COMMUNITY CARE CENTER OF LOUISIANA, INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | MAPLE GROVE LODGE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 437 SOVEREIGN CT | ||||||||
| Address2: | |||||||||
| City: | BALLWIN | ||||||||
| State: | MO | ||||||||
| PostalCode: | 630114432 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3663943000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2407 KENTUCKY STREET | ||||||||
| Address2: | |||||||||
| City: | LOUISIANA | ||||||||
| State: | MO | ||||||||
| PostalCode: | 633532503 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5737545456 | ||||||||
| FaxNumber: | 5737546624 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/30/2005 | ||||||||
| LastUpdateDate: | 03/04/2021 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GIARDINA | ||||||||
| AuthorizedOfficialFirstName: | CHRISTINA | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6363943000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 03/04/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 033696 | MO | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 102299302 | 05 | MO | MEDICAID |