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General NPI Number Information
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NPI Number | 1255408423
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Entity Type | Organization
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Legal Business Name | CLASSIC COUNTRY LIVING INCORPORATED
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Dates
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Enumeration Date | 11/30/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 109 SAVANAH JON BLVD
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City | BOERNE
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State | TX
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Zip | 78015-8399
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Country | US
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Telephone | 830-336-4040
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Fax | 830-336-4054
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Provider Business Mailing Address
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Address Line | 109 SAVANAH JON BLVD
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City | BOERNE
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State | TX
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Zip | 78015-8399
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Country | US
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Telephone | 830-336-4040
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Fax | 830-336-4054
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Authorized Official
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Title or Position | ADMINISTRATOR AND MANAGER
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Name | MRS. STARLETTE ROSE ROGGE
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Credential |
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Telephone | 830-336-4040
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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 | 117205
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License Number State | TX
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