Provider Demographics
NPI:1780859330
Name:COUNTRY LIVING ADULT FAMILY HOME
Entity Type:Organization
Organization Name:COUNTRY LIVING ADULT FAMILY HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADULT FAM HOME PROVIDER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ERMELINDA
Authorized Official - Middle Name:V
Authorized Official - Last Name:KNUPP
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:253-875-6663
Mailing Address - Street 1:21514 47TH AVE E
Mailing Address - Street 2:
Mailing Address - City:SPANAWAY
Mailing Address - State:WA
Mailing Address - Zip Code:98387
Mailing Address - Country:US
Mailing Address - Phone:253-875-6663
Mailing Address - Fax:253-875-6663
Practice Address - Street 1:21514 47TH AVE E
Practice Address - Street 2:
Practice Address - City:SPANAWAY
Practice Address - State:WA
Practice Address - Zip Code:98387
Practice Address - Country:US
Practice Address - Phone:253-875-6663
Practice Address - Fax:253-875-6663
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-24
Last Update Date:2008-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA750777311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home