Provider Demographics
NPI:1194718908
Name:CLARK COUNTY NURSING HOME
Entity type:Organization
Organization Name:CLARK COUNTY NURSING HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:TAMMY
Authorized Official - Middle Name:
Authorized Official - Last Name:MCDANIEL-RAMSEY
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:660-727-3303
Mailing Address - Street 1:1260 N JOHNSON ST
Mailing Address - Street 2:
Mailing Address - City:KAHOKA
Mailing Address - State:MO
Mailing Address - Zip Code:63445-1100
Mailing Address - Country:US
Mailing Address - Phone:660-727-3303
Mailing Address - Fax:660-727-3736
Practice Address - Street 1:1260 N JOHNSON ST
Practice Address - Street 2:
Practice Address - City:KAHOKA
Practice Address - State:MO
Practice Address - Zip Code:63445-1100
Practice Address - Country:US
Practice Address - Phone:660-727-3303
Practice Address - Fax:660-727-3736
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-26
Last Update Date:2009-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO035239314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO101483709Medicaid
MO261483705Medicaid
MO261483705Medicaid