Healthcare Provider Details

I. General information

NPI: 1841875234
Provider Name (Legal Business Name): COUNTRYSIDE CARE CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/16/2021
Last Update Date: 07/06/2021
Certification Date: 07/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

925 N CORNELIA AVE
FRESNO CA
93706-1031
US

IV. Provider business mailing address

925 N CORNELIA AVE
FRESNO CA
93706-1031
US

V. Phone/Fax

Practice location:
  • Phone: 559-554-2024
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number State

VIII. Authorized Official

Name: TARA RAYMOND
Title or Position: ADMINISTRATOR
Credential:
Phone: 559-275-4785