1720405582 NPI number — COUNTRY CARE RESIDENTIAL SERVICES, INC.

Table of content: (NPI 1720405582)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720405582 NPI number — COUNTRY CARE RESIDENTIAL SERVICES, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COUNTRY CARE RESIDENTIAL SERVICES, INC.
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:
1720405582
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/31/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1036 2200TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
IOLA
Provider Business Mailing Address State Name:
KS
Provider Business Mailing Address Postal Code:
66749-3085
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
620-365-6033
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11 HOLIDAY CT
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
IOLA
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
66749-1515
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
620-228-8316
Provider Business Practice Location Address Fax Number:
620-365-6033
Provider Enumeration Date:
03/18/2014

Additional Information

Authorized Official

Authorized Official Last Name:
MALEY
Authorized Official First Name:
JOYCE
Authorized Official Middle Name:
ANN
Authorized Official Title or Position:
PROVIDER
Authorized Official Telephone Number:
620-365-6033

Provider Taxonomy Codes

  • Taxonomy code: 251C00000X , registered in the state of KS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1720405582 , issued by the state of ( KS ) . This identifiers is of the category "MEDICAID".




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