Organization
KOUNTRY TRAILS
Active
Organization subpart
No
Provider details
NPI number
Authorized official
JANE JOHNSON (OWNER)
(910) 521-7788
Entity
Organization
Contact information
Practice address
527 WOODS RD, PEMBROKE, NC 28372-8099
(910) 521-7788
(910) 521-7788
Mailing address
PO BOX 925, PEMBROKE, NC 28372-0925
(910) 521-7788
(910) 521-7788
Taxonomy
Speciality
Code
Description
License number
State
251C00000X
Developmentally Disabled Services Day Training Agency
Primary
MHL078154
NC
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
8301033
—
NC
Enumeration date
01/18/2007
Last updated
10/05/2007
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