=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780859330
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COUNTRY LIVING ADULT FAMILY HOME
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/24/2008
-----------------------------------------------------
Last Update Date | 04/24/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 21514 47TH AVE E
-----------------------------------------------------
City | SPANAWAY
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98387
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 253-875-6663
-----------------------------------------------------
Fax | 253-875-6663
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 21514 47TH AVE E
-----------------------------------------------------
City | SPANAWAY
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98387
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 253-875-6663
-----------------------------------------------------
Fax | 253-875-6663
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADULT FAM HOME PROVIDER
-----------------------------------------------------
Name | MRS. ERMELINDA V KNUPP
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 253-875-6663
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 311ZA0620X
-----------------------------------------------------
Taxonomy Name | Adult Care Home Facility
-----------------------------------------------------
License Number | 750777
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------