Basic Information
| Provider Information | |||||||||
| NPI: | 1295274785 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COUNTRY AIRE OPERATIONS MANAGEMENT LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 33 WEDGEWOOD LN | ||||||||
| Address2: | |||||||||
| City: | LAWRENCE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 115591451 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9178360436 | ||||||||
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| Practice Location | |||||||||
| Address1: | 18540 STATE HIGHWAY 16 | ||||||||
| Address2: | |||||||||
| City: | LEWISTOWN | ||||||||
| State: | MO | ||||||||
| PostalCode: | 634522111 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5732152216 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/16/2017 | ||||||||
| LastUpdateDate: | 02/16/2017 | ||||||||
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| AuthorizedOfficialLastName: | STOLL | ||||||||
| AuthorizedOfficialFirstName: | GERALD | ||||||||
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| AuthorizedOfficialTitleorPosition: | MANAGING MEMBER | ||||||||
| AuthorizedOfficialTelephone: | 9178360436 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | AMO SNF MANAGEMENT LLC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 310400000X | N | Nursing & Custodial Care Facilities | Assisted Living Facility | 314000000X | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
No ID Information.