Healthcare Provider Details

I. General information

NPI: 1083146633
Provider Name (Legal Business Name): COUNTRYSIDE FAMILY CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/03/2017
Last Update Date: 04/03/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1041 US HIGHWAY 231 N
HARTFORD KY
42347-9402
US

IV. Provider business mailing address

PO BOX 585
HARTFORD KY
42347-0585
US

V. Phone/Fax

Practice location:
  • Phone: 270-233-2024
  • Fax: 270-233-0202
Mailing address:
  • Phone: 270-233-2024
  • Fax: 270-233-0202

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number3008378
License Number StateKY

VIII. Authorized Official

Name: ELAINE M BERRY
Title or Position: OFFCIE MANAGER
Credential: CPC
Phone: 270-233-2024