Healthcare Provider Details

I. General information

NPI: 1790723211
Provider Name (Legal Business Name): COUNTRYSIDE HOSPICE CARE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/04/2006
Last Update Date: 08/03/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

320 BRANSCOMB DR SW SUITE D
JACKSONVILLE AL
36265
US

IV. Provider business mailing address

101 SUN AVE NE
ALBUQUERQUE NM
87109-4373
US

V. Phone/Fax

Practice location:
  • Phone: 256-235-2999
  • Fax: 256-782-3590
Mailing address:
  • Phone: 505-468-5604
  • Fax: 505-468-4681

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251G00000X
TaxonomyCommunity Based Hospice Care Agency
License Number
License Number State

VIII. Authorized Official

Name: MR. GLEN CAVALLO
Title or Position: SR. VP OF OPERATIONS
Credential:
Phone: 479-996-5900