Healthcare Provider Details

I. General information

NPI: 1629293238
Provider Name (Legal Business Name): COUNTRY ROAD RESOURCES, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/17/2007
Last Update Date: 06/21/2022
Certification Date: 06/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25687 HWY 371
SAREPTA LA
71071
US

IV. Provider business mailing address

PO BOX 93
SAREPTA LA
71071-0093
US

V. Phone/Fax

Practice location:
  • Phone: 318-847-4193
  • Fax: 318-847-4192
Mailing address:
  • Phone: 318-847-4193
  • Fax: 318-847-4192

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3747P1801X
TaxonomyPersonal Care Attendant
License Number1461041
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name: MRS. JOHNIECE WHITEHEAD
Title or Position: DIRECTOR
Credential:
Phone: 318-847-4193