Provider Demographics
NPI:1093116998
Name:COUNTRYHOUSE RESIDENCES
Entity Type:Organization
Organization Name:COUNTRYHOUSE RESIDENCES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:MYRBERG
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:402-964-2060
Mailing Address - Street 1:5030 S 155TH ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68137-5002
Mailing Address - Country:US
Mailing Address - Phone:402-964-2060
Mailing Address - Fax:
Practice Address - Street 1:5030 S 155TH ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68137-5002
Practice Address - Country:US
Practice Address - Phone:402-964-2060
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-10
Last Update Date:2014-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE2988311500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311500000XNursing & Custodial Care FacilitiesAlzheimer Center (Dementia Center)