Provider Demographics
NPI:1982818522
Name:COUNTRY VILLAGE COMMUNITY CARE HOME INC
Entity Type:Organization
Organization Name:COUNTRY VILLAGE COMMUNITY CARE HOME INC
Other - Org Name:WASHINGTON ELMS
Other - Org Type:Other Name
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:EDGAR
Authorized Official - Middle Name:
Authorized Official - Last Name:GREASON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:802-463-4722
Mailing Address - Street 1:99 ATKINSON ST
Mailing Address - Street 2:PO BOX 468
Mailing Address - City:BELLOWS FALLS
Mailing Address - State:VT
Mailing Address - Zip Code:05101-1302
Mailing Address - Country:US
Mailing Address - Phone:802-463-4722
Mailing Address - Fax:802-463-1986
Practice Address - Street 1:99 ATKINSON ST
Practice Address - Street 2:
Practice Address - City:BELLOWS FALLS
Practice Address - State:VT
Practice Address - Zip Code:05101-1302
Practice Address - Country:US
Practice Address - Phone:802-463-4722
Practice Address - Fax:802-463-1986
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT0018251K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT047W189Medicaid
VT047W140Medicaid