Provider Demographics
NPI:1720405582
Name:COUNTRY CARE RESIDENTIAL SERVICES, INC.
Entity Type:Organization
Organization Name:COUNTRY CARE RESIDENTIAL SERVICES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:JOYCE
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:MALEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:620-365-6033
Mailing Address - Street 1:1036 2200TH ST
Mailing Address - Street 2:
Mailing Address - City:IOLA
Mailing Address - State:KS
Mailing Address - Zip Code:66749-3085
Mailing Address - Country:US
Mailing Address - Phone:620-365-6033
Mailing Address - Fax:
Practice Address - Street 1:11 HOLIDAY CT
Practice Address - Street 2:
Practice Address - City:IOLA
Practice Address - State:KS
Practice Address - Zip Code:66749-1515
Practice Address - Country:US
Practice Address - Phone:620-228-8316
Practice Address - Fax:620-365-6033
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-18
Last Update Date:2014-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS251C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS1720405582Medicaid