Healthcare Provider Details

I. General information

NPI: 1518054139
Provider Name (Legal Business Name): COUNTRYSIDE CONTINUING CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/06/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1865 COUNTRYSIDE DR
FREMONT OH
43420-8748
US

IV. Provider business mailing address

1865 COUNTRYSIDE DR
FREMONT OH
43420-8748
US

V. Phone/Fax

Practice location:
  • Phone: 419-334-2602
  • Fax:
Mailing address:
  • Phone: 419-334-2602
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number6160
License Number StateOH

VIII. Authorized Official

Name: MRS. LINDA BLACK-KUREK
Title or Position: OWNER
Credential:
Phone: 937-296-1550