Provider Demographics
NPI:1265791347
Name:COUNTRY ANGELS
Entity type:Organization
Organization Name:COUNTRY ANGELS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:O
Authorized Official - Last Name:CASE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:620-856-5418
Mailing Address - Street 1:2067 E 12TH ST
Mailing Address - Street 2:
Mailing Address - City:BAXTER SPRINGS
Mailing Address - State:KS
Mailing Address - Zip Code:66713-2657
Mailing Address - Country:US
Mailing Address - Phone:620-856-5418
Mailing Address - Fax:620-856-1932
Practice Address - Street 1:2067 E 12TH ST
Practice Address - Street 2:
Practice Address - City:BAXTER SPRINGS
Practice Address - State:KS
Practice Address - Zip Code:66713-2657
Practice Address - Country:US
Practice Address - Phone:620-856-5418
Practice Address - Fax:620-856-1932
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-10
Last Update Date:2012-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KSB011001310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200637940AMedicaid