Healthcare Provider Details

I. General information

NPI: 1336252089
Provider Name (Legal Business Name): COUNTRYSIDE HEALTH SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/16/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

HIGHWAY 64 EAST
WARNER OK
74469-0749
US

IV. Provider business mailing address

PO BOX 749
WARNER OK
74469-0749
US

V. Phone/Fax

Practice location:
  • Phone: 918-463-5143
  • Fax: 918-463-5144
Mailing address:
  • Phone: 918-463-5143
  • Fax: 918-463-5144

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code313M00000X
TaxonomyNursing Facility/Intermediate Care Facility
License NumberNH51025102
License Number StateOK

VIII. Authorized Official

Name: JACK SCOTT ROGERS
Title or Position: ADMINISTRATOR
Credential:
Phone: 918-463-5143