Provider Demographics
NPI:1740474360
Name:COUNTRY LIVING RETIREMENT HOME
Entity type:Organization
Organization Name:COUNTRY LIVING RETIREMENT HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:RUTH
Authorized Official - Middle Name:J
Authorized Official - Last Name:GRIFFIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-552-7501
Mailing Address - Street 1:181 OLD MILL ROAD
Mailing Address - Street 2:
Mailing Address - City:FUQUAY-VARINA
Mailing Address - State:NC
Mailing Address - Zip Code:27526-6177
Mailing Address - Country:US
Mailing Address - Phone:919-552-7501
Mailing Address - Fax:
Practice Address - Street 1:181 OLD MILL ROAD
Practice Address - Street 2:
Practice Address - City:FUQUAY-VARINA
Practice Address - State:NC
Practice Address - Zip Code:27526-6177
Practice Address - Country:US
Practice Address - Phone:919-552-7501
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-28
Last Update Date:2007-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility