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General NPI Number Information
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NPI Number | 1386984565
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Entity Type | Organization
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Legal Business Name | COUNTRY LIVING MANAGEMENT COMPANY
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Dates
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Enumeration Date | 02/25/2013
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Last Update Date | 02/25/2013
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Provider Practice Location Address
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Address Line | 4000 COUNTY ROAD 15 SW
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City | MONTEVIDEO
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State | MN
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Zip | 56265-4005
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Country | US
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Telephone | 320-269-9000
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Fax | 320-269-8008
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Provider Business Mailing Address
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Address Line | 12335 13TH ST NW
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City | SPICER
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State | MN
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Zip | 56288-9316
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Country | US
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Telephone | 320-269-9000
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Fax | 320-269-8008
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Authorized Official
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Title or Position | CEO
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Name | LUANNE GIBSON
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Credential |
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Telephone | 32026990001
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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 | 360364
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License Number State | MN
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