Healthcare Provider Details

I. General information

NPI: 1093620502
Provider Name (Legal Business Name): COUNTRY ROOTS HOME CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/18/2026
Last Update Date: 08/18/2026
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1806 M ST. SUITE 206
BELLEVILLE KS
66935-2206
US

IV. Provider business mailing address

1806 M ST. SUITE 206
BELLEVILLE KS
66935-2206
US

V. Phone/Fax

Practice location:
  • Phone: 316-284-1046
  • Fax:
Mailing address:
  • Phone: 316-284-1046
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State

VIII. Authorized Official

Name: ELISA MIRANDA COTTENMYRE
Title or Position: OWNER/ADMINISTRATOR
Credential:
Phone: 316-284-1046