Provider Demographics
NPI:1104183243
Name:CASUAL COUNTRY LIVING INC.
Entity type:Organization
Organization Name:CASUAL COUNTRY LIVING INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:NANCY
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:DUNLEAVY
Authorized Official - Suffix:
Authorized Official - Credentials:CORE TRANING
Authorized Official - Phone:321-632-9622
Mailing Address - Street 1:4801 MANGO AVE
Mailing Address - Street 2:
Mailing Address - City:COCOA
Mailing Address - State:FL
Mailing Address - Zip Code:32926-2921
Mailing Address - Country:US
Mailing Address - Phone:321-632-9622
Mailing Address - Fax:321-632-9622
Practice Address - Street 1:4801 MANGO AVE
Practice Address - Street 2:
Practice Address - City:COCOA
Practice Address - State:FL
Practice Address - Zip Code:32926-2921
Practice Address - Country:US
Practice Address - Phone:321-632-9622
Practice Address - Fax:321-632-9622
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-13
Last Update Date:2012-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL10167310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility