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General NPI Number Information
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NPI Number | 1417135682
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Entity Type | Organization
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Legal Business Name | COUNTRY LIVING ASSISTED CARE CENTER INC
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Dates
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Enumeration Date | 02/09/2008
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Last Update Date | 10/31/2008
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Provider Practice Location Address
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Address Line | 1762 SW ARCH ST
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City | PORT SAINT LUCIE
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State | FL
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Zip | 34953-1558
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Country | US
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Telephone | 772-621-8211
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Fax | 772-621-8211
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Provider Business Mailing Address
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Address Line | 1762 SW ARCH ST
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City | PORT SAINT LUCIE
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State | FL
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Zip | 34953-1558
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Country | US
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Telephone | 772-621-8211
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Fax | 772-621-8211
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Authorized Official
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Title or Position | ADM
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Name | CAROL ANN CAMMARSANA
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Credential |
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Telephone | 772-626-1150
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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 | AL11331
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License Number State | FL
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