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General NPI Number Information
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NPI Number | 1003001033
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Entity Type | Organization
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Legal Business Name | COUNTRY CARE INC
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Dates
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Enumeration Date | 09/12/2007
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Last Update Date | 09/12/2007
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Provider Practice Location Address
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Address Line | 3980 E CASSIE LANE
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City | COTTONWOOD
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State | AZ
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Zip | 86326
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Country | US
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Telephone | 928-649-0434
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Fax | 928-649-0238
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Provider Business Mailing Address
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Address Line | 5302 N 43RD PLACE
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City | PHOENIX
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State | AZ
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Zip | 85018-1672
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Country | US
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Telephone | 928-274-0702
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Fax | 602-808-9186
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Authorized Official
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Title or Position | PRESIDENT
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Name | MR. MICHAEL THOMAS HARRIS
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Credential |
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Telephone | 928-274-0702
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 310400000X
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Taxonomy Name | Assisted Living Facility
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License Number | ALH4144
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License Number State | AZ
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