Provider Demographics
NPI:1730221102
Name:COUNTRY MANOR REST HOME INC.
Entity type:Organization
Organization Name:COUNTRY MANOR REST HOME INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SARAH
Authorized Official - Middle Name:
Authorized Official - Last Name:UPCHURCH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-498-2353
Mailing Address - Street 1:PO BOX 281
Mailing Address - Street 2:
Mailing Address - City:RANDLEMAN
Mailing Address - State:NC
Mailing Address - Zip Code:27317-0281
Mailing Address - Country:US
Mailing Address - Phone:336-498-2353
Mailing Address - Fax:336-498-5972
Practice Address - Street 1:2061 MILLBORO RD
Practice Address - Street 2:
Practice Address - City:FRANKLINVILLE
Practice Address - State:NC
Practice Address - Zip Code:27248-8219
Practice Address - Country:US
Practice Address - Phone:336-498-5353
Practice Address - Fax:336-498-5972
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCHAL076002311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7803803Medicaid