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General NPI Number Information
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NPI Number | 1245493816
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Entity Type | Organization
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Legal Business Name | COUNTRY MANOR LIVING
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Dates
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Enumeration Date | 07/03/2008
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Last Update Date | 07/03/2008
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Provider Practice Location Address
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Address Line | 170 PHILLIPS ST
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City | JEROME
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State | PA
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Zip | 15937-0430
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Country | US
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Telephone | 814-479-2355
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Fax | 814-479-4047
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Provider Business Mailing Address
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Address Line | 170 PHILLIPS ST PO BOX 430
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City | JEROME
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State | PA
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Zip | 15937
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Country | US
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Telephone | 814-479-2355
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Fax | 814-479-4047
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Authorized Official
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Title or Position | ADMINISTRATOR
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Name | MRS. LORIE ANN HORNICK
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Credential |
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Telephone | 814-479-2355
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251J00000X
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Taxonomy Name | Nursing Care Agency
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License Number | 001320
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License Number State | PA
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