1407070808 NPI number — COUNTRY CARE CENTER, CORP

Table of content: (NPI 1407070808)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407070808 NPI number — COUNTRY CARE CENTER, CORP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COUNTRY CARE CENTER, CORP
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1407070808
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 351
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HARLAN
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
51537-0351
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
712-744-3453
Provider Business Mailing Address Fax Number:
712-744-3458

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
725 HIGHWAY 59
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HARLAN
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
51537-6709
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
712-744-3453
Provider Business Practice Location Address Fax Number:
712-744-3458
Provider Enumeration Date:
04/13/2007

Additional Information

Authorized Official

Authorized Official Last Name:
MCQUEEN
Authorized Official First Name:
CATHERINE
Authorized Official Middle Name:
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
712-744-3453

Provider Taxonomy Codes

  • Taxonomy code: 320600000X , with the licence number:  R390 , registered in the state of IA ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 320900000X , with the licence number: R390 , registered in the state of IA ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0735639 . This is a "HCBS WAIVER" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".
  • Identifier: 0894006 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0238410 . This is a "SCL" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".
  • Identifier: 0747410 . This is a "DAY HABILITATION" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".




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