Provider Demographics
NPI:1548589583
Name:COUNTRY COTTAGE, INC
Entity Type:Organization
Organization Name:COUNTRY COTTAGE, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINSTRATIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:SUZETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:MIDDLETON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:435-673-2211
Mailing Address - Street 1:1240 E 100 S #202
Mailing Address - Street 2:
Mailing Address - City:ST. GEORGE
Mailing Address - State:UT
Mailing Address - Zip Code:84790
Mailing Address - Country:US
Mailing Address - Phone:435-673-2211
Mailing Address - Fax:435-673-1241
Practice Address - Street 1:1240 E 100 S STE 202
Practice Address - Street 2:
Practice Address - City:ST GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84790-3077
Practice Address - Country:US
Practice Address - Phone:435-673-2211
Practice Address - Fax:435-673-1241
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-28
Last Update Date:2010-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1312147-0140253J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253J00000XAgenciesFoster Care Agency