Provider Demographics
NPI:1609248855
Name:COUNTRY LIVING ESTATES, INC
Entity Type:Organization
Organization Name:COUNTRY LIVING ESTATES, INC
Other - Org Name:COUNTRY LIVING ESTATES ASSISTED LIVING FACILITY
Other - Org Type:Other Name
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:HILDA
Authorized Official - Middle Name:
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-484-1701
Mailing Address - Street 1:4761 DRAUGHON RD
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28312-8480
Mailing Address - Country:US
Mailing Address - Phone:910-484-1701
Mailing Address - Fax:910-484-1703
Practice Address - Street 1:4761 DRAUGHON RD
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28312-8480
Practice Address - Country:US
Practice Address - Phone:910-484-1701
Practice Address - Fax:910-484-1703
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-28
Last Update Date:2015-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC310400000X, 311ZA0620X, 344600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
No311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
No344600000XTransportation ServicesTaxi