Healthcare Provider Details

I. General information

NPI: 1003524430
Provider Name (Legal Business Name): COUNTRY DRIVE INN MEDICAL PRACTICE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/15/2022
Last Update Date: 12/15/2025
Certification Date: 12/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10825 TOWNSHIP ROAD 49
MOUNT PERRY OH
43760-9779
US

IV. Provider business mailing address

10825 TOWNSHIP ROAD 49
MOUNT PERRY OH
43760-9779
US

V. Phone/Fax

Practice location:
  • Phone: 740-221-6550
  • Fax:
Mailing address:
  • Phone: 740-221-6550
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: ARICA REEVES
Title or Position: OWNER/PROVIDER
Credential: APRN
Phone: 740-221-6550