Healthcare Provider Details

I. General information

NPI: 1063498285
Provider Name (Legal Business Name): COUNTRYSIDE CARE CENTRE LP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/20/2005
Last Update Date: 02/20/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2330 W GALENA BLVD
AURORA IL
60506-4246
US

IV. Provider business mailing address

2330 W GALENA BLVD
AURORA IL
60506-4246
US

V. Phone/Fax

Practice location:
  • Phone: 630-896-4686
  • Fax: 630-896-7868
Mailing address:
  • Phone: 630-896-4686
  • Fax: 630-896-7868

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number40931
License Number StateIL

VIII. Authorized Official

Name: MR. MICHAEL CHARLES BRAUN
Title or Position: CONTROLLER
Credential:
Phone: 847-583-0100