Healthcare Provider Details

I. General information

NPI: 1306313051
Provider Name (Legal Business Name): COUNTRY CARE FAMILY CLINIC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/31/2018
Last Update Date: 10/31/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3 E CLEVELAND AVE
ELLSINORE MO
63937
US

IV. Provider business mailing address

PO BOX 446
ELLSINORE MO
63937-0446
US

V. Phone/Fax

Practice location:
  • Phone: 573-429-6698
  • Fax:
Mailing address:
  • Phone: 573-429-6698
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: LAURA VICTORIA NANCE
Title or Position: NURSE PRACTITIONER/ OFFICE MANAGER
Credential: NP-C
Phone: 573-429-6698