Provider Demographics
NPI:1942476395
Name:COUNTRY LIVING ADULT DAY CARE INC.
Entity Type:Organization
Organization Name:COUNTRY LIVING ADULT DAY CARE INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF NURSING
Authorized Official - Prefix:MRS
Authorized Official - First Name:JANETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:HAMILTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-361-7778
Mailing Address - Street 1:5622 DELMAR BLVD
Mailing Address - Street 2:SUITE102
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63112-2600
Mailing Address - Country:US
Mailing Address - Phone:314-361-7778
Mailing Address - Fax:314-361-7776
Practice Address - Street 1:5622 DELMAR BLVD
Practice Address - Street 2:SUITE102
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63112-2600
Practice Address - Country:US
Practice Address - Phone:314-361-7778
Practice Address - Fax:314-361-7776
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-06
Last Update Date:2008-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1518189141Medicaid