Provider Demographics
NPI:1407070808
Name:COUNTRY CARE CENTER, CORP
Entity Type:Organization
Organization Name:COUNTRY CARE CENTER, CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:CATHERINE
Authorized Official - Middle Name:
Authorized Official - Last Name:MCQUEEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:712-744-3453
Mailing Address - Street 1:PO BOX 351
Mailing Address - Street 2:
Mailing Address - City:HARLAN
Mailing Address - State:IA
Mailing Address - Zip Code:51537-0351
Mailing Address - Country:US
Mailing Address - Phone:712-744-3453
Mailing Address - Fax:712-744-3458
Practice Address - Street 1:725 HIGHWAY 59
Practice Address - Street 2:
Practice Address - City:HARLAN
Practice Address - State:IA
Practice Address - Zip Code:51537-6709
Practice Address - Country:US
Practice Address - Phone:712-744-3453
Practice Address - Fax:712-744-3458
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAR390320600000X, 320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
Not Answered320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0735639OtherHCBS WAIVER
IA0894006Medicaid
IA0238410OtherSCL
IA0747410OtherDAY HABILITATION