=====================================================
General NPI Number Information
=====================================================
NPI Number | 1447632302
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LIVING COUNTRY HOME CARE SERVICES, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/26/2015
-----------------------------------------------------
Last Update Date | 09/16/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2753 SE 4001
-----------------------------------------------------
City | ANDREWS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79714-5958
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 432-238-0378
-----------------------------------------------------
Fax | 432-203-2357
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 30 VILLAGE CIR STE B
-----------------------------------------------------
City | MIDLAND
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79701-6345
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 432-686-1977
-----------------------------------------------------
Fax | 432-686-1978
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/ADMINISTRATOR
-----------------------------------------------------
Name | MR. JESUS A CHAVEZ JR.
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 432-238-0378
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------