Healthcare Provider Details

I. General information

NPI: 1386966919
Provider Name (Legal Business Name): COUNTRYSIDE NURSING AND REHABILITATION CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/24/2010
Last Update Date: 02/24/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1635 E 154TH ST
DOLTON IL
60419-3001
US

IV. Provider business mailing address

1635 E 154TH ST
DOLTON IL
60419-3001
US

V. Phone/Fax

Practice location:
  • Phone: 708-841-9550
  • Fax: 708-841-4517
Mailing address:
  • Phone: 708-841-9550
  • Fax: 708-841-4517

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number0050708
License Number StateIL

VIII. Authorized Official

Name: MR. JOE ZIMMERMAN
Title or Position: CEO
Credential:
Phone: 847-905-4000