Provider Demographics
NPI:1346847621
Name:THE COUNTRY COTTAGE LLC
Entity Type:Organization
Organization Name:THE COUNTRY COTTAGE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPERATOR
Authorized Official - Prefix:
Authorized Official - First Name:DABRINA
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:BLOCKER
Authorized Official - Suffix:
Authorized Official - Credentials:REGISTERED NURSE
Authorized Official - Phone:850-516-0400
Mailing Address - Street 1:1962 WELL LINE RD
Mailing Address - Street 2:
Mailing Address - City:CANTONMENT
Mailing Address - State:FL
Mailing Address - Zip Code:32533-7807
Mailing Address - Country:US
Mailing Address - Phone:850-516-0400
Mailing Address - Fax:
Practice Address - Street 1:1851 W TEN MILE RD
Practice Address - Street 2:
Practice Address - City:CANTONMENT
Practice Address - State:FL
Practice Address - Zip Code:32533-7758
Practice Address - Country:US
Practice Address - Phone:850-476-1246
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-10-08
Last Update Date:2020-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility