Provider Demographics
NPI:1376532051
Name:TOWN AND COUNTRY MANOR CHRISTIAN & MISSIONARY ALLIANCE
Entity Type:Organization
Organization Name:TOWN AND COUNTRY MANOR CHRISTIAN & MISSIONARY ALLIANCE
Other - Org Name:TOWN AND COUNTRY MANOR
Other - Org Type:Other Name
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DIRK
Authorized Official - Middle Name:
Authorized Official - Last Name:DEWOLFE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:714-547-7581
Mailing Address - Street 1:555 E MEMORY LANE
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92706-1705
Mailing Address - Country:US
Mailing Address - Phone:714-547-7581
Mailing Address - Fax:714-547-0435
Practice Address - Street 1:555 E MEMORY LANE
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92706-1705
Practice Address - Country:US
Practice Address - Phone:714-547-7581
Practice Address - Fax:714-547-0435
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-17
Last Update Date:2020-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA060000191313M00000X
332BN1400X, 332BP3500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
No332BN1400XSuppliersDurable Medical Equipment & Medical SuppliesNursing Facility Supplies
No332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZT 11308 FMedicaid
CA555141Medicare ID - Type UnspecifiedMEDICARE
CAZZT 11308 FMedicaid