Provider Demographics
NPI:1780067785
Name:COUNTRY NICHE ADULT DAY CARE
Entity type:Organization
Organization Name:COUNTRY NICHE ADULT DAY CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JENNIE
Authorized Official - Middle Name:
Authorized Official - Last Name:FRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-436-5727
Mailing Address - Street 1:PO BOX 150493
Mailing Address - Street 2:
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84415-0493
Mailing Address - Country:US
Mailing Address - Phone:801-436-5727
Mailing Address - Fax:
Practice Address - Street 1:2179 W 1800 N STE D
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:UT
Practice Address - Zip Code:84015-7900
Practice Address - Country:US
Practice Address - Phone:801-436-5727
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-08
Last Update Date:2015-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385H00000XRespite Care FacilityRespite Care