Provider Demographics
NPI:1619274669
Name:COUNTRY LIVING ADULT FOSTER CARE
Entity Type:Organization
Organization Name:COUNTRY LIVING ADULT FOSTER CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:GAIL
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:DAWSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:231-823-2061
Mailing Address - Street 1:16966 6 MILE RD
Mailing Address - Street 2:
Mailing Address - City:STANWOOD
Mailing Address - State:MI
Mailing Address - Zip Code:49346-9104
Mailing Address - Country:US
Mailing Address - Phone:231-823-2061
Mailing Address - Fax:231-823-2061
Practice Address - Street 1:16966 6 MILE RD
Practice Address - Street 2:
Practice Address - City:STANWOOD
Practice Address - State:MI
Practice Address - Zip Code:49346-9104
Practice Address - Country:US
Practice Address - Phone:231-823-2061
Practice Address - Fax:231-823-2061
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-26
Last Update Date:2011-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIAS5403071743104A0625X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3104A0625XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIAS540307174OtherLICENSE #
MI=========OtherEIN