MEDICARE: COUNTRYSIDE CONVALESCENT HOME LIMITED PARTNERSHIP

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	310400000X	Assisted Living Facility

General Provider Information

NPI Number	:	1639917198
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COUNTRYSIDE CONVALESCENT HOME LIMITED PARTNERSHIP

Provider Business Mailing Address
First Line	:	612 N MAIN ST
Second Line	:
City	:	BUTLER
State	:	PA
Zip	:	16001-4363
Country	:	US
Telephone Number	:	724-431-0770
Fax Number	:

Provider Business Practice Location Address
First Line	:	8221 LAMOR ROAD
Second Line	:
City	:	MERCER
State	:	PA
Zip	:	16137-3163
Country	:	US
Telephone Number	:	724-458-9501
Fax Number	:	724-662-1090

Authorized Official
Title or Position	:	CFO
Name	:	MICHAEL MARKIVICH
Credential	:
Telephone Number	:	724-431-0770

Provider Enumeration Date	:	07/18/2024
Last Update Date	:	07/18/2024

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1376537431 — COUNTRYSIDE CONVALESCENT HOME LIMITED PARTNERSHIP
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8221 LAMOR RD
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