Provider Demographics
NPI:1417135682
Name:COUNTRY LIVING ASSISTED CARE CENTER INC
Entity Type:Organization
Organization Name:COUNTRY LIVING ASSISTED CARE CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADM
Authorized Official - Prefix:
Authorized Official - First Name:CAROL
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:CAMMARSANA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:772-626-1150
Mailing Address - Street 1:1762 SW ARCH ST
Mailing Address - Street 2:
Mailing Address - City:PORT SAINT LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34953-1558
Mailing Address - Country:US
Mailing Address - Phone:772-621-8211
Mailing Address - Fax:772-621-8211
Practice Address - Street 1:1762 SW ARCH ST
Practice Address - Street 2:
Practice Address - City:PORT SAINT LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34953-1558
Practice Address - Country:US
Practice Address - Phone:772-621-8211
Practice Address - Fax:772-621-8211
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-09
Last Update Date:2008-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL11331310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL692697596OtherMEDWAIVER