Provider Demographics
NPI:1922004407
Name:COUNTRY OAKS CARE CENTER, INC
Entity Type:Organization
Organization Name:COUNTRY OAKS CARE CENTER, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASSISTANT ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHARON
Authorized Official - Middle Name:L
Authorized Official - Last Name:HENNING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:805-922-6657
Mailing Address - Street 1:830 E CHAPEL ST
Mailing Address - Street 2:
Mailing Address - City:SANTA MARIA
Mailing Address - State:CA
Mailing Address - Zip Code:93454-4610
Mailing Address - Country:US
Mailing Address - Phone:805-922-6657
Mailing Address - Fax:805-928-9283
Practice Address - Street 1:830 E CHAPEL ST
Practice Address - Street 2:
Practice Address - City:SANTA MARIA
Practice Address - State:CA
Practice Address - Zip Code:93454-4610
Practice Address - Country:US
Practice Address - Phone:805-922-6657
Practice Address - Fax:805-928-9283
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZT05826HMedicaid
CAZZT05826HMedicaid