Provider Demographics
NPI:1003524430
Name:COUNTRY DRIVE INN MEDICAL PRACTICE
Entity Type:Organization
Organization Name:COUNTRY DRIVE INN MEDICAL PRACTICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:ARICA
Authorized Official - Middle Name:
Authorized Official - Last Name:REEVES
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:740-683-5165
Mailing Address - Street 1:10825 TOWNSHIP ROAD 49
Mailing Address - Street 2:
Mailing Address - City:MOUNT PERRY
Mailing Address - State:OH
Mailing Address - Zip Code:43760-9779
Mailing Address - Country:US
Mailing Address - Phone:740-683-5165
Mailing Address - Fax:
Practice Address - Street 1:10825 TOWNSHIP ROAD 49
Practice Address - Street 2:
Practice Address - City:MOUNT PERRY
Practice Address - State:OH
Practice Address - Zip Code:43760-9779
Practice Address - Country:US
Practice Address - Phone:740-683-5165
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-11-15
Last Update Date:2024-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
No261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0053044Medicaid