Basic Information
| Provider Information | |||||||||
| NPI: | 1720190788 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CHRISTIAN CARE HOME | ||||||||
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| Mailing Information | |||||||||
| Address1: | 800 CHAMBERS RD | ||||||||
| Address2: | |||||||||
| City: | FERGUSON | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631352133 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3145228100 | ||||||||
| FaxNumber: | 3145222334 | ||||||||
| Practice Location | |||||||||
| Address1: | 800 CHAMBERS RD | ||||||||
| Address2: | |||||||||
| City: | FERGUSON | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631352133 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3145228100 | ||||||||
| FaxNumber: | 3145222334 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2006 | ||||||||
| LastUpdateDate: | 01/06/2012 | ||||||||
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| AuthorizedOfficialLastName: | FINK | ||||||||
| AuthorizedOfficialFirstName: | CHARLOTTE | ||||||||
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| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 3145228100 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332BP3500X | 4842620001 | MO | N | Suppliers | Durable Medical Equipment & Medical Supplies | Parenteral & Enteral Nutrition | 314000000X | 030395 | MO | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 101483501 | 05 | MO | MEDICAID |