Provider Demographics
NPI:1245382092
Name:COUNTRY LAYNE, LLC
Entity type:Organization
Organization Name:COUNTRY LAYNE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ANDETRA
Authorized Official - Middle Name:M
Authorized Official - Last Name:SAMPSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-740-3575
Mailing Address - Street 1:PO BOX 270
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE
Mailing Address - State:NC
Mailing Address - Zip Code:28372-0270
Mailing Address - Country:US
Mailing Address - Phone:910-740-3575
Mailing Address - Fax:910-521-7435
Practice Address - Street 1:42 THREE HUNT'S DR
Practice Address - Street 2:
Practice Address - City:PEMBROKE
Practice Address - State:NC
Practice Address - Zip Code:28372-8998
Practice Address - Country:US
Practice Address - Phone:910-740-3575
Practice Address - Fax:910-521-7435
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-18
Last Update Date:2009-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHI078153251C00000X
NCMHL078153251C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8301032RMedicaid
NC8301032Medicaid