Provider Demographics
NPI:1437266558
Name:COUNTRY ESTATES NURSING, L.L.C.
Entity Type:Organization
Organization Name:COUNTRY ESTATES NURSING, L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASSISTANT SECRETARY
Authorized Official - Prefix:MS
Authorized Official - First Name:MARILYN
Authorized Official - Middle Name:
Authorized Official - Last Name:WEAVER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:502-596-7563
Mailing Address - Street 1:680 S 4TH ST # KH-2
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40202-2407
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1200 SUFFIELD ST
Practice Address - Street 2:
Practice Address - City:AGAWAM
Practice Address - State:MA
Practice Address - Zip Code:01001-2933
Practice Address - Country:US
Practice Address - Phone:413-789-2200
Practice Address - Fax:413-789-2269
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-24
Last Update Date:2018-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA0967314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA982257OtherMULTIPLAN
MA1190138OtherUNITED HEALTH CARE
MA000000024954OtherBMC HEALTH NET
MA71-01051OtherCIGNA
MA0029577OtherMARTINS POINT
MA225642OtherCCS
MA0927929Medicaid
MA2222564201OtherBLUE CROSS BLUE SHIELD
225642Medicare Oscar/Certification