Provider Demographics
NPI:1457507972
Name:COUNTRY VILLAGE ESTATES L.L.C.
Entity Type:Organization
Organization Name:COUNTRY VILLAGE ESTATES L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:LOUIS
Authorized Official - Middle Name:GEORGE
Authorized Official - Last Name:DUGAL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:207-728-3570
Mailing Address - Street 1:260 DUGAL DRIVE
Mailing Address - Street 2:
Mailing Address - City:MADAWASKA
Mailing Address - State:ME
Mailing Address - Zip Code:04756
Mailing Address - Country:US
Mailing Address - Phone:207-728-3570
Mailing Address - Fax:207-728-4475
Practice Address - Street 1:260 DUGAL DRIVE
Practice Address - Street 2:
Practice Address - City:MADAWASKA
Practice Address - State:ME
Practice Address - Zip Code:04756
Practice Address - Country:US
Practice Address - Phone:207-728-3570
Practice Address - Fax:207-728-4475
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-15
Last Update Date:2008-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEALLS3139310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME433013600Medicaid