Provider Demographics
NPI:1073523692
Name:COUNTRY PLACE HEALTH CARE CENTER
Entity Type:Organization
Organization Name:COUNTRY PLACE HEALTH CARE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:CYNTHIA
Authorized Official - Middle Name:A
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:931-484-4782
Mailing Address - Street 1:PO BOX 687
Mailing Address - Street 2:80 JUSTICE STREET
Mailing Address - City:CROSSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38557
Mailing Address - Country:US
Mailing Address - Phone:931-484-4782
Mailing Address - Fax:931-456-0309
Practice Address - Street 1:80 JUSTICE STREET
Practice Address - Street 2:
Practice Address - City:CROSSVILLE
Practice Address - State:TN
Practice Address - Zip Code:38555
Practice Address - Country:US
Practice Address - Phone:931-484-4782
Practice Address - Fax:931-456-0309
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000000285314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN7440421Medicaid
TN0445167Medicaid
TN50919OtherBCBS
TN7440421Medicaid