MEDICARE: COUNTRY ANGELS

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	310400000X	Assisted Living Facility	B011001	KS

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	:	1265791347
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COUNTRY ANGELS

Provider Business Mailing Address
First Line	:	2067 E 12TH ST
Second Line	:
City	:	BAXTER SPRINGS
State	:	KS
Zip	:	66713-2657
Country	:	US
Telephone Number	:	620-856-5418
Fax Number	:	620-856-1932

Provider Business Practice Location Address
First Line	:	2067 E 12TH ST
Second Line	:
City	:	BAXTER SPRINGS
State	:	KS
Zip	:	66713-2657
Country	:	US
Telephone Number	:	620-856-5418
Fax Number	:	620-856-1932

Authorized Official
Title or Position	:	OWNER
Name	:	MR. GARY O CASE
Credential	:
Telephone Number	:	620-856-5418

Provider Enumeration Date	:	05/10/2012
Last Update Date	:	05/10/2012

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Directions to “COUNTRY ANGELS ” Practice Location

Language	Start Address	Practice Location

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