Healthcare Provider Details

I. General information

NPI: 1952887549
Provider Name (Legal Business Name): COUNTRYSIDE MANOR NURSING AND REHABILITATION LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/17/2018
Last Update Date: 07/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1865 COUNTRYSIDE DR
FREMONT OH
43420-8748
US

IV. Provider business mailing address

15 AMERICA AVE UNIT 304
LAKEWOOD NJ
08701-4582
US

V. Phone/Fax

Practice location:
  • Phone: 419-334-2602
  • Fax: 419-344-6287
Mailing address:
  • Phone: 513-487-7479
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number2362N
License Number StateOH

VIII. Authorized Official

Name: HAYLEY WILLIAMS
Title or Position: ATTORNEY
Credential:
Phone: 216-706-3936