Provider Demographics
NPI:1306313051
Name:COUNTRY CARE FAMILY CLINIC, LLC
Entity type:Organization
Organization Name:COUNTRY CARE FAMILY CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER/ OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:VICTORIA
Authorized Official - Last Name:NANCE
Authorized Official - Suffix:
Authorized Official - Credentials:NP-C
Authorized Official - Phone:573-429-6698
Mailing Address - Street 1:PO BOX 446
Mailing Address - Street 2:
Mailing Address - City:ELLSINORE
Mailing Address - State:MO
Mailing Address - Zip Code:63937-0446
Mailing Address - Country:US
Mailing Address - Phone:573-429-6698
Mailing Address - Fax:
Practice Address - Street 1:3 E CLEVELAND AVE
Practice Address - Street 2:
Practice Address - City:ELLSINORE
Practice Address - State:MO
Practice Address - Zip Code:63937
Practice Address - Country:US
Practice Address - Phone:573-429-6698
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-10-31
Last Update Date:2018-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care