MEDICARE: COUNTRY PLACE VILLAGE I LP

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	100561	TX

General Provider Information

NPI Number	:	1891817094
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COUNTRY PLACE VILLAGE I LP

Provider Business Mailing Address
First Line	:	PO BOX 479
Second Line	:
City	:	TYLER
State	:	TX
Zip	:	75710-0479
Country	:	US
Telephone Number	:	903-566-8500
Fax Number	:	903-566-8506

Provider Business Practice Location Address
First Line	:	2103 CHANDLER ST
Second Line	:
City	:	KILGORE
State	:	TX
Zip	:	75662-3741
Country	:	US
Telephone Number	:	903-984-7827
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT CEO
Name	:	BRIAN K CLARKE
Credential	:
Telephone Number	:	903-566-8500

Provider Enumeration Date	:	04/06/2007
Last Update Date	:	08/22/2020

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