Healthcare Provider Details

I. General information

NPI: 1578050100
Provider Name (Legal Business Name): COUNTRY CARRIAGE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/19/2018
Last Update Date: 04/19/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10180 GERDANVILLE AVE SE
WAYNESBURG OH
44688-9323
US

IV. Provider business mailing address

PO BOX 173
WAYNESBURG OH
44688-0173
US

V. Phone/Fax

Practice location:
  • Phone: 330-356-9022
  • Fax:
Mailing address:
  • Phone: 330-356-9022
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number4161822
License Number StateOH

VIII. Authorized Official

Name: TARI ANNE HOOVER
Title or Position: CO-PARTENER
Credential:
Phone: 330-356-9022