Healthcare Provider Details

I. General information

NPI: 1982839569
Provider Name (Legal Business Name): COUNTRY COMFORT CRCF
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/26/2009
Last Update Date: 05/26/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

204 JOE APREE CIR
BLYTHEWOOD SC
29016-8807
US

IV. Provider business mailing address

204 JOE APREE CIR
BLYTHEWOOD SC
29016-8807
US

V. Phone/Fax

Practice location:
  • Phone: 803-735-9777
  • Fax:
Mailing address:
  • Phone: 803-735-9777
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License NumberCRC-1467
License Number StateSC

VIII. Authorized Official

Name: CLIFFORD ALAN COUNTS
Title or Position: OWNER / ADMINISTRATOR
Credential:
Phone: 803-735-9777