Provider Demographics
NPI:1952424152
Name:COUNTRY PINES FAMILY CARE HOME
Entity Type:Organization
Organization Name:COUNTRY PINES FAMILY CARE HOME
Other - Org Name:COUNTRY PINES II
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHIRLEY
Authorized Official - Middle Name:J
Authorized Official - Last Name:CARSWELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:828-438-2886
Mailing Address - Street 1:5415 ROB CARSWELL ST
Mailing Address - Street 2:
Mailing Address - City:MORGANTON
Mailing Address - State:NC
Mailing Address - Zip Code:28655-9438
Mailing Address - Country:US
Mailing Address - Phone:828-438-2886
Mailing Address - Fax:828-437-0429
Practice Address - Street 1:3041 COUNTRY PINES ST
Practice Address - Street 2:
Practice Address - City:MORGANTON
Practice Address - State:NC
Practice Address - Zip Code:28655-0122
Practice Address - Country:US
Practice Address - Phone:828-438-2886
Practice Address - Fax:828-334-3439
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-10
Last Update Date:2024-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCFCL 012017310400000X
310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7802855Medicaid