MEDICARE: COUNTRYSIDE MEDICAL CLINIC, LLC

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	261QP2300X	Primary Care Clinic/Center

General Provider Information

NPI Number	:	1396103685
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COUNTRYSIDE MEDICAL CLINIC, LLC

Provider Business Mailing Address
First Line	:	1959 200TH ST
Second Line	:
City	:	RED OAK
State	:	IA
Zip	:	51566-3218
Country	:	US
Telephone Number	:	712-629-0040
Fax Number	:	712-566-5049

Provider Business Practice Location Address
First Line	:	1959 200TH ST
Second Line	:
City	:	RED OAK
State	:	IA
Zip	:	51566-3218
Country	:	US
Telephone Number	:	712-629-0040
Fax Number	:	712-566-5049

Authorized Official
Title or Position	:	NURSE PRACTITIONER
Name	:	MS. KIMBERLY LYNN RINES
Credential	:	ARNP
Telephone Number	:	712-629-0040

Provider Enumeration Date	:	02/02/2016
Last Update Date	:	12/12/2018

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