Provider Demographics
NPI:1972758688
Name:COUNTRY MEDICAL SERVICES, LLC
Entity Type:Organization
Organization Name:COUNTRY MEDICAL SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER OF BUSINESS/ NP-C PROVIDER
Authorized Official - Prefix:MS
Authorized Official - First Name:DIANA
Authorized Official - Middle Name:LOUISE
Authorized Official - Last Name:LEWIS
Authorized Official - Suffix:
Authorized Official - Credentials:NP-C
Authorized Official - Phone:575-666-2475
Mailing Address - Street 1:# 1252, NM STATE HIGHWAY 120 (FYI RURAL ADDRESS)
Mailing Address - Street 2:POB 203
Mailing Address - City:OCATE
Mailing Address - State:NM
Mailing Address - Zip Code:87734-0203
Mailing Address - Country:US
Mailing Address - Phone:575-666-2475
Mailing Address - Fax:800-560-1129
Practice Address - Street 1:NM STATE HIGHWAY 120, #1252 (FYI RURAL ADDRESS)
Practice Address - Street 2:POB 203
Practice Address - City:OCATE
Practice Address - State:NM
Practice Address - Zip Code:87734-0203
Practice Address - Country:US
Practice Address - Phone:575-666-2475
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-21
Last Update Date:2011-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMR24775364SF0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes364SF0001XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistFamily HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM22002570Medicaid
NMQ60378Medicare UPIN