MEDICARE: COUNTRY LIVING CARE CENTER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	311ZA0620X	Adult Care Home Facility	R419	IA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1033376603
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COUNTRY LIVING CARE CENTER

Provider Business Mailing Address
First Line	:	2840 K AVE
Second Line	:
City	:	TOLEDO
State	:	IA
Zip	:	52342-9405
Country	:	US
Telephone Number	:	641-484-3561
Fax Number	:	641-484-3651

Provider Business Practice Location Address
First Line	:	2840 K AVE
Second Line	:
City	:	TOLEDO
State	:	IA
Zip	:	52342-9405
Country	:	US
Telephone Number	:	641-484-3561
Fax Number	:	641-484-3651

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MS. TERRI L MAYO
Credential	:
Telephone Number	:	641-484-3561

Provider Enumeration Date	:	05/20/2008
Last Update Date	:	05/20/2008

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Directions to “COUNTRY LIVING CARE CENTER ” Practice Location

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