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General NPI Number Information
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NPI Number | 1396890158
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Entity Type | Organization
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Legal Business Name | COUNTRY CLINIC MEDICAL SERVICES INC
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Dates
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Enumeration Date | 01/24/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 120 NE DARTMOOR DR
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City | WAUKEE
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State | IA
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Zip | 50263-9660
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Country | US
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Telephone | 515-987-3117
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Fax | 515-987-3119
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Provider Business Mailing Address
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Address Line | 120 NE DARTMOOR DR PO BOX 968
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City | WAUKEE
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State | IA
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Zip | 50263-9660
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Country | US
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Telephone | 515-987-3117
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Fax | 515-987-3119
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Authorized Official
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Title or Position | OWNER
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Name | DR. KIM K COUNTRYMAN
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Credential | D.O.
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Telephone | 515-987-3117
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 02312
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License Number State | IA
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