Provider Demographics
NPI:1578050100
Name:COUNTRY CARRIAGE LLC
Entity Type:Organization
Organization Name:COUNTRY CARRIAGE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-PARTENER
Authorized Official - Prefix:
Authorized Official - First Name:TARI
Authorized Official - Middle Name:ANNE
Authorized Official - Last Name:HOOVER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:330-356-9022
Mailing Address - Street 1:PO BOX 173
Mailing Address - Street 2:
Mailing Address - City:WAYNESBURG
Mailing Address - State:OH
Mailing Address - Zip Code:44688-0173
Mailing Address - Country:US
Mailing Address - Phone:330-356-9022
Mailing Address - Fax:
Practice Address - Street 1:10180 GERDANVILLE AVE SE
Practice Address - Street 2:
Practice Address - City:WAYNESBURG
Practice Address - State:OH
Practice Address - Zip Code:44688-9323
Practice Address - Country:US
Practice Address - Phone:330-356-9022
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-19
Last Update Date:2018-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4161822343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)