Provider Demographics
NPI:1629219910
Name:COUNTRY CLUB HOME CARE LLC
Entity Type:Organization
Organization Name:COUNTRY CLUB HOME CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ROSE MARIE
Authorized Official - Middle Name:
Authorized Official - Last Name:MANSEL
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:248-626-8500
Mailing Address - Street 1:4120 W MAPLE RD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:BLOOMFIELD HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48301-3010
Mailing Address - Country:US
Mailing Address - Phone:248-626-8500
Mailing Address - Fax:248-539-9740
Practice Address - Street 1:4120 W MAPLE RD
Practice Address - Street 2:SUITE 201
Practice Address - City:BLOOMFIELD HILLS
Practice Address - State:MI
Practice Address - Zip Code:48301-3010
Practice Address - Country:US
Practice Address - Phone:248-626-8500
Practice Address - Fax:248-539-9740
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-16
Last Update Date:2009-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care