Provider Demographics
NPI:1669473104
Name:COUNTRY STYLE HEALTH CARE INC X
Entity type:Organization
Organization Name:COUNTRY STYLE HEALTH CARE INC X
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:W
Authorized Official - Last Name:EDDINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-539-2427
Mailing Address - Street 1:2301 HIGHWAY 1187 STE 203
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:TX
Mailing Address - Zip Code:76063-6139
Mailing Address - Country:US
Mailing Address - Phone:817-539-2427
Mailing Address - Fax:817-549-4150
Practice Address - Street 1:1317 N 16TH AVE
Practice Address - Street 2:
Practice Address - City:DURANT
Practice Address - State:OK
Practice Address - Zip Code:74701-2134
Practice Address - Country:US
Practice Address - Phone:580-931-3055
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-09
Last Update Date:2024-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKHC7690251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK1002627408AMedicaid
OK377631Medicare Oscar/Certification