Provider Demographics
NPI:1588997431
Name:COUNTRY VILLA SERVICE CORP.
Entity type:Organization
Organization Name:COUNTRY VILLA SERVICE CORP.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT - CAMS
Authorized Official - Prefix:MS
Authorized Official - First Name:CHERYL
Authorized Official - Middle Name:
Authorized Official - Last Name:PETTERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-574-3733
Mailing Address - Street 1:5120 W GOLDLEAF CIR STE 400
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90056-1297
Mailing Address - Country:US
Mailing Address - Phone:310-574-3733
Mailing Address - Fax:
Practice Address - Street 1:5120 W GOLDLEAF CIR STE 400
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90056-1297
Practice Address - Country:US
Practice Address - Phone:310-574-3733
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-10
Last Update Date:2009-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility