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General NPI Number Information
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NPI Number | 1265791347
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Entity Type | Organization
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Legal Business Name | COUNTRY ANGELS
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Dates
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Enumeration Date | 05/10/2012
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Last Update Date | 05/10/2012
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Provider Practice Location Address
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Address Line | 2067 E 12TH ST
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City | BAXTER SPRINGS
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State | KS
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Zip | 66713-2657
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Country | US
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Telephone | 620-856-5418
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Fax | 620-856-1932
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Provider Business Mailing Address
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Address Line | 2067 E 12TH ST
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City | BAXTER SPRINGS
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State | KS
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Zip | 66713-2657
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Country | US
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Telephone | 620-856-5418
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Fax | 620-856-1932
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Authorized Official
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Title or Position | OWNER
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Name | MR. GARY O CASE
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Credential |
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Telephone | 620-856-5418
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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 | B011001
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License Number State | KS
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