MEDICARE: COUNTRYSIDE HOSPICE CARE, INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251G00000X	Community Based Hospice Care Agency	028-0350-H	GA

General Provider Information

NPI Number	:	1013248814
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COUNTRYSIDE HOSPICE CARE, INC

Provider Business Mailing Address
First Line	:	203 OAKSIDE LN
Second Line	:	BUILDING 203-B
City	:	CANTON
State	:	GA
Zip	:	30114-6407
Country	:	US
Telephone Number	:	770-704-9982
Fax Number	:

Provider Business Practice Location Address
First Line	:	203 OAKSIDE LN
Second Line	:	BUILDING 203, SUITE B
City	:	CANTON
State	:	GA
Zip	:	30114-6407
Country	:	US
Telephone Number	:	770-704-9982
Fax Number	:	770-704-2755

Authorized Official
Title or Position	:	SR. VP - OPERATIONS
Name	:	MR. GLEN CAVALLO
Credential	:
Telephone Number	:	479-996-5900

Provider Enumeration Date	:	01/19/2010
Last Update Date	:	02/16/2012

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