Provider Demographics
NPI:1871896456
Name:COUNTRY CLUB HOME CARE LLC
Entity type:Organization
Organization Name:COUNTRY CLUB HOME CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:ROSE
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:MANSEL
Authorized Official - Suffix:
Authorized Official - Credentials:REGISTERED NURSE
Authorized Official - Phone:248-346-1233
Mailing Address - Street 1:2554 S ROCHESTER RD
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48307-3817
Mailing Address - Country:US
Mailing Address - Phone:866-596-9111
Mailing Address - Fax:866-596-9111
Practice Address - Street 1:6477 HERITAGE
Practice Address - Street 2:
Practice Address - City:WEST BLOOMFIELD
Practice Address - State:MI
Practice Address - Zip Code:48322-1339
Practice Address - Country:US
Practice Address - Phone:866-596-9111
Practice Address - Fax:866-596-9111
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-21
Last Update Date:2010-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704245086251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health