Provider Demographics
NPI:1629293238
Name:COUNTRY ROAD RESOURCES, INC
Entity Type:Organization
Organization Name:COUNTRY ROAD RESOURCES, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:JOHNIECE
Authorized Official - Middle Name:
Authorized Official - Last Name:WHITEHEAD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-847-4193
Mailing Address - Street 1:PO BOX 93
Mailing Address - Street 2:
Mailing Address - City:SAREPTA
Mailing Address - State:LA
Mailing Address - Zip Code:71071-0093
Mailing Address - Country:US
Mailing Address - Phone:318-847-4193
Mailing Address - Fax:318-847-4192
Practice Address - Street 1:25687 HWY 371
Practice Address - Street 2:
Practice Address - City:SAREPTA
Practice Address - State:LA
Practice Address - Zip Code:71071
Practice Address - Country:US
Practice Address - Phone:318-847-4193
Practice Address - Fax:318-847-4192
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-17
Last Update Date:2022-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
253Z00000X
LA14610413747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care AttendantGroup - Single Specialty
No253Z00000XAgenciesIn Home Supportive CareGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1461041Medicaid