Provider Demographics
NPI:1922153329
Name:COUNTRY LIVING AND MORE FAMILY CARE
Entity Type:Organization
Organization Name:COUNTRY LIVING AND MORE FAMILY CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COOWNER COADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:828-453-0006
Mailing Address - Street 1:336 NC 120 HWY
Mailing Address - Street 2:
Mailing Address - City:MOORESBORO
Mailing Address - State:NC
Mailing Address - Zip Code:28114-7788
Mailing Address - Country:US
Mailing Address - Phone:828-453-0006
Mailing Address - Fax:828-453-1542
Practice Address - Street 1:336 NC 120 HWY
Practice Address - Street 2:
Practice Address - City:MOORESBORO
Practice Address - State:NC
Practice Address - Zip Code:28114-7788
Practice Address - Country:US
Practice Address - Phone:828-453-0006
Practice Address - Fax:828-453-1542
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCFCL-081-016310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7801846Medicare ID - Type UnspecifiedPROVIDER MEDICARE