Basic Information
| Provider Information | |||||||||
| NPI: | 1649734146 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COUNTRY MEADOWS HEALTH AND REHABILITATION LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | COUNTRY MEADOWS NURSING AND REHABILITATION CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1422 CLARKVIEW RD | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212092385 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4105138738 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3301 W PARK ROW BLVD | ||||||||
| Address2: | |||||||||
| City: | CORSICANA | ||||||||
| State: | TX | ||||||||
| PostalCode: | 751104846 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9038722455 | ||||||||
| FaxNumber: | 9038747286 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/29/2019 | ||||||||
| LastUpdateDate: | 01/16/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | REYNOLDS | ||||||||
| AuthorizedOfficialFirstName: | BRIAN | ||||||||
| AuthorizedOfficialMiddleName: | K. | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGER, AUTHORIZED OFFICIAL | ||||||||
| AuthorizedOfficialTelephone: | 4105138738 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 01/16/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 4977 | 05 | TX | MEDICAID | 001030458 | 05 | TX | MEDICAID |