Provider Demographics
NPI:1245493816
Name:COUNTRY MANOR LIVING
Entity type:Organization
Organization Name:COUNTRY MANOR LIVING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:LORIE
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:HORNICK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:814-479-2355
Mailing Address - Street 1:170 PHILLIPS ST
Mailing Address - Street 2:PO BOX 430
Mailing Address - City:JEROME
Mailing Address - State:PA
Mailing Address - Zip Code:15937
Mailing Address - Country:US
Mailing Address - Phone:814-479-2355
Mailing Address - Fax:814-479-4047
Practice Address - Street 1:170 PHILLIPS ST
Practice Address - Street 2:
Practice Address - City:JEROME
Practice Address - State:PA
Practice Address - Zip Code:15937-0430
Practice Address - Country:US
Practice Address - Phone:814-479-2355
Practice Address - Fax:814-479-4047
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-03
Last Update Date:2008-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA001320251J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251J00000XAgenciesNursing Care