Provider Demographics
NPI:1528211703
Name:COUNTRY OAK VILLAGE
Entity Type:Organization
Organization Name:COUNTRY OAK VILLAGE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:E
Authorized Official - Last Name:HAMBLIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:816-224-2700
Mailing Address - Street 1:101 CROSS CREEK DR
Mailing Address - Street 2:
Mailing Address - City:GRAIN VALLEY
Mailing Address - State:MO
Mailing Address - Zip Code:64029-9561
Mailing Address - Country:US
Mailing Address - Phone:816-224-2700
Mailing Address - Fax:816-224-3335
Practice Address - Street 1:101 CROSS CREEK DR
Practice Address - Street 2:
Practice Address - City:GRAIN VALLEY
Practice Address - State:MO
Practice Address - Zip Code:64029-9561
Practice Address - Country:US
Practice Address - Phone:816-224-2700
Practice Address - Fax:816-224-3335
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-31
Last Update Date:2008-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO034569310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility