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General NPI Number Information
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NPI Number | 1508996901
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Entity Type | Organization
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Legal Business Name | COUNTRY LIFE HEALTH CARE INC
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Dates
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Enumeration Date | 03/06/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 2554 FORD AVE
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City | OSKALOOSA
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State | IA
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Zip | 52577-8850
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Country | US
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Telephone | 641-673-4447
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Fax | 641-673-4447
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Provider Business Mailing Address
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Address Line | 2554 FORD AVE
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City | OSKALOOSA
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State | IA
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Zip | 52577-8850
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Country | US
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Telephone | 641-673-4447
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Fax | 641-673-4447
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Authorized Official
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Title or Position | ADMINISTRATOR
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Name | MR. ROBERT KEITH KELLEY
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Credential |
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Telephone | 641-673-4447
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 311Z00000X
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Taxonomy Name | Custodial Care Facility
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License Number | 620603
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License Number State | IA
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