Provider Demographics
NPI:1053712943
Name:C.R. OF COOSA VALLEY, LLC
Entity type:Organization
Organization Name:C.R. OF COOSA VALLEY, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:E
Authorized Official - Last Name:WINGET
Authorized Official - Suffix:SR
Authorized Official - Credentials:
Authorized Official - Phone:478-994-3669
Mailing Address - Street 1:513 PINEVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:GLENCOE
Mailing Address - State:AL
Mailing Address - Zip Code:35905-1803
Mailing Address - Country:US
Mailing Address - Phone:256-492-5350
Mailing Address - Fax:256-492-5352
Practice Address - Street 1:513 PINEVIEW AVE
Practice Address - Street 2:
Practice Address - City:GLENCOE
Practice Address - State:AL
Practice Address - Zip Code:35905-1803
Practice Address - Country:US
Practice Address - Phone:256-492-5350
Practice Address - Fax:256-492-5352
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-10
Last Update Date:2014-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
015174Medicare Oscar/Certification