Healthcare Provider Details

I. General information

NPI: 1073677951
Provider Name (Legal Business Name): COUNTRY HAVEN ASSISTED LIVING, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/21/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13812 HIRAM RD
WILLS POINT TX
75169-8652
US

IV. Provider business mailing address

13812 HIRAM RD
WILLS POINT TX
75169-8652
US

V. Phone/Fax

Practice location:
  • Phone: 972-524-9884
  • Fax: 972-524-9884
Mailing address:
  • Phone: 972-524-9884
  • Fax: 972-524-9884

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number119106
License Number StateTX

VIII. Authorized Official

Name: MS. JUANITA M. BERG
Title or Position: PRESIDENT
Credential: R.N.
Phone: 972-524-9884