Provider Demographics
NPI:1083874242
Name:COUNTRY LIVING ADULT FOSTER CARE
Entity type:Organization
Organization Name:COUNTRY LIVING ADULT FOSTER CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER OPERATOR
Authorized Official - Prefix:
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:CHARLOTTE
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:LVN
Authorized Official - Phone:830-444-1395
Mailing Address - Street 1:175 COUNTY ROAD 6721
Mailing Address - Street 2:
Mailing Address - City:NATALIA
Mailing Address - State:TX
Mailing Address - Zip Code:78059-2123
Mailing Address - Country:US
Mailing Address - Phone:830-444-1394
Mailing Address - Fax:
Practice Address - Street 1:175 COUNTY ROAD 6721
Practice Address - Street 2:
Practice Address - City:NATALIA
Practice Address - State:TX
Practice Address - Zip Code:78059-2123
Practice Address - Country:US
Practice Address - Phone:830-444-1395
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-11
Last Update Date:2019-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX121380253J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253J00000XAgenciesFoster Care Agency