Healthcare Provider Details

I. General information

NPI: 1336135318
Provider Name (Legal Business Name): COUNTRYSIDE HOME CARE, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/23/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1213 MAIN ST
SALMON ID
83467-4324
US

IV. Provider business mailing address

1213 MAIN ST
SALMON ID
83467-4324
US

V. Phone/Fax

Practice location:
  • Phone: 208-756-4032
  • Fax: 208-756-6477
Mailing address:
  • Phone: 208-756-4032
  • Fax: 208-756-6477

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State

VIII. Authorized Official

Name: JOHN GROVER
Title or Position: OWNER/ADMINISTRATOR
Credential:
Phone: 208-756-4032