Provider Demographics
NPI:1821179789
Name:COUNTRY MEADOWS NURSING & REHAB LLC
Entity Type:Organization
Organization Name:COUNTRY MEADOWS NURSING & REHAB LLC
Other - Org Name:COUNTRY MEADOWS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:C
Authorized Official - Last Name:LINCOLN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-481-9625
Mailing Address - Street 1:1301 NORTH SAINT JOE DRIVE
Mailing Address - Street 2:
Mailing Address - City:PARK HILLS
Mailing Address - State:MO
Mailing Address - Zip Code:63601-1965
Mailing Address - Country:US
Mailing Address - Phone:573-431-2889
Mailing Address - Fax:573-431-2822
Practice Address - Street 1:1301 NORTH SAINT JOE DRIVE
Practice Address - Street 2:
Practice Address - City:PARK HILLS
Practice Address - State:MO
Practice Address - Zip Code:63601-1965
Practice Address - Country:US
Practice Address - Phone:573-431-2889
Practice Address - Fax:573-431-2822
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-18
Last Update Date:2008-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO032558310400000X
MO032557314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO267889103Medicaid
MO102534500Medicaid
MO267889103Medicaid