Provider Demographics
NPI:1376900811
Name:COUNTRY HOME ASSISTED LIVING LLC DBA COUNTRY HOME
Entity Type:Organization
Organization Name:COUNTRY HOME ASSISTED LIVING LLC DBA COUNTRY HOME
Other - Org Name:COUNTRY HOME
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:CHRISTINE
Authorized Official - Last Name:MELBARDIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:303-840-1986
Mailing Address - Street 1:1425 DEBBIE CIR
Mailing Address - Street 2:
Mailing Address - City:PARKER
Mailing Address - State:CO
Mailing Address - Zip Code:80138-4702
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1425 DEBBIE CIR
Practice Address - Street 2:
Practice Address - City:PARKER
Practice Address - State:CO
Practice Address - Zip Code:80138-4702
Practice Address - Country:US
Practice Address - Phone:303-840-1986
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-27
Last Update Date:2021-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO23040Q310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility