Healthcare Provider Details

I. General information

NPI: 1164597688
Provider Name (Legal Business Name): COUNTRYSIDE CARE CENTER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/21/2006
Last Update Date: 02/02/2023
Certification Date: 02/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2121 ROBINSON RD
JACKSON MI
49203-3658
US

IV. Provider business mailing address

2121 ROBINSON RD
JACKSON MI
49203-3658
US

V. Phone/Fax

Practice location:
  • Phone: 517-787-4150
  • Fax:
Mailing address:
  • Phone: 517-787-4150
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number38-4180
License Number StateMI

VIII. Authorized Official

Name: JOHN GANTON
Title or Position: ADMINISTRATOR
Credential:
Phone: 517-787-4150