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General NPI Number Information
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NPI Number | 1871896456
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Entity Type | Organization
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Legal Business Name | COUNTRY CLUB HOME CARE LLC
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Dates
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Enumeration Date | 12/21/2010
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Last Update Date | 12/21/2010
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Provider Practice Location Address
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Address Line | 6477 HERITAGE
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City | WEST BLOOMFIELD
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State | MI
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Zip | 48322-1339
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Country | US
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Telephone | 866-596-9111
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Fax | 866-596-9111
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Provider Business Mailing Address
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Address Line | 2554 S ROCHESTER RD
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City | ROCHESTER HILLS
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State | MI
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Zip | 48307-3817
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Country | US
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Telephone | 866-596-9111
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Fax | 866-596-9111
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Authorized Official
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Title or Position | OWNER
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Name | MS. ROSE MARIE MANSEL
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Credential | REGISTERED NURSE
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Telephone | 248-346-1233
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251E00000X
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Taxonomy Name | Home Health Agency
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License Number | 4704245086
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License Number State | MI
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