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General NPI Number Information
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NPI Number | 1669804811
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Entity Type | Organization
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Legal Business Name | COUNTRY COMFORT RETIREMENT HOMES, INC
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Dates
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Enumeration Date | 07/30/2013
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Last Update Date | 07/30/2013
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Provider Practice Location Address
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Address Line | 615 PATRICIA LN
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City | HENRY
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State | IL
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Zip | 61537-1037
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Country | US
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Telephone | 309-364-3607
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Fax | 309-364-4065
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Provider Business Mailing Address
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Address Line | PO BOX 186
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City | HENRY
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State | IL
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Zip | 61537-0186
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Country | US
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Telephone | 309-364-3607
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Fax | 309-364-4065
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Authorized Official
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Title or Position | OWNER, NURSE MANAGER
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Name | SHERYL LYNN PETTETT
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Credential | LPN
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Telephone | 309-364-3607
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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 | 5104325
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License Number State | IL
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Taxonomy #2
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Taxonomy Code | 311500000X
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Taxonomy Name | Alzheimer Center (Dementia Center)
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License Number | 5104325
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License Number State | IL
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