Provider Demographics
NPI:1093317000
Name:COUNTRY AIR VILLA LLC
Entity Type:Organization
Organization Name:COUNTRY AIR VILLA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:ANDREA
Authorized Official - Middle Name:
Authorized Official - Last Name:CARGILL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-769-2963
Mailing Address - Street 1:8835 NORTHCUTT RD
Mailing Address - Street 2:
Mailing Address - City:FAIRBURN
Mailing Address - State:GA
Mailing Address - Zip Code:30213-2278
Mailing Address - Country:US
Mailing Address - Phone:404-769-2963
Mailing Address - Fax:770-964-5565
Practice Address - Street 1:8835 NORTHCUTT RD
Practice Address - Street 2:
Practice Address - City:FAIRBURN
Practice Address - State:GA
Practice Address - Zip Code:30213-2278
Practice Address - Country:US
Practice Address - Phone:404-769-2963
Practice Address - Fax:770-964-5565
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-11-13
Last Update Date:2020-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251J00000XAgenciesNursing Care