Provider Demographics
NPI:1194930677
Name:COUNTRY ROSE MANOR
Entity type:Organization
Organization Name:COUNTRY ROSE MANOR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER ADMINSTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:DONNA
Authorized Official - Middle Name:JEAN
Authorized Official - Last Name:DESCHAINE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:907-348-0009
Mailing Address - Street 1:14041 SABINE ST
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99516-3910
Mailing Address - Country:US
Mailing Address - Phone:907-348-0009
Mailing Address - Fax:907-344-6767
Practice Address - Street 1:14041 SABINE ST
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99516-3910
Practice Address - Country:US
Practice Address - Phone:907-348-0009
Practice Address - Fax:907-344-6767
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK100130310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKRL0936OtherPROVIDER INDENTIFACTION