Country Manor Assisted Living & Retirement Home, LLC

Primary specialty

Assisted Living Facility (Mental Illness)Taxonomy code 3104A0625X

License

12025 Issued in FL

Legal business name

COUNTRY MANOR ASSISTED LIVING & RETIREMENT HOME, LLC

Practice address

1152 Old Hammock Rd
Port Orange, FL 32129-5016

Phone

(386) 265-5935

Fax

(386) 265-5937

NPI assigned

Dec 27, 2013

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Mr. Arnulfo Salgado Simondac

Title

Administrator

Phone

(386) 589-6252

Specialties & licenses 1

Addresses

Locations

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1388102400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1388102400000",
    "number": "1104247717",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1152 OLD HAMMOCK RD",
            "city": "PORT ORANGE",
            "state": "FL",
            "postal_code": "321295016",
            "telephone_number": "386-265-5935",
            "fax_number": "386-265-5937"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1152 OLD HAMMOCK RD",
            "city": "PORT ORANGE",
            "state": "FL",
            "postal_code": "321295016",
            "telephone_number": "386-265-5935",
            "fax_number": "386-265-5937"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "COUNTRY MANOR ASSISTED LIVING & RETIREMENT HOME, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2013-12-27",
        "last_updated": "2013-12-27",
        "status": "A",
        "authorized_official_last_name": "SIMONDAC",
        "authorized_official_first_name": "ARNULFO",
        "authorized_official_middle_name": "SALGADO",
        "authorized_official_title_or_position": "ADMINISTRATOR",
        "authorized_official_telephone_number": "386-589-6252",
        "authorized_official_name_prefix": "Mr."
    },
    "taxonomies": [
        {
            "code": "3104A0625X",
            "taxonomy_group": "",
            "desc": "Assisted Living Facility, Assisted Living, Mental Illness",
            "state": "FL",
            "license": "12025",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Sara Rebecca Corwin, FNP-C
• Caitlin Costello
• Joseph Couche
• Counseling & Consultation, Corp.
• Counseling Associates of Port Orange, Inc.
• Sharyn Coville
• Rebecca Cowden
• Caitlyn Coyne, BCABA
• Sean Douglas Crafton, DC
• Olivia Craig

• Assisted Living Facility (Mental Illness) in Port Orange, FL
• Providers in Port Orange, FL by specialty
• Assisted Living Facility (Mental Illness) in Florida

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 27, 2013; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.