Healthcare Provider Details

I. General information

NPI: 1336391127
Provider Name (Legal Business Name): COUNTRYSIDE THERAPY SERVICE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/13/2008
Last Update Date: 10/13/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

W4523 COUNTY ROAD IW
WALDO WI
53093-1639
US

IV. Provider business mailing address

PO BOX 1127
SHEBOYGAN WI
53082-1127
US

V. Phone/Fax

Practice location:
  • Phone: 920-564-6107
  • Fax:
Mailing address:
  • Phone: 920-457-6750
  • Fax: 920-457-8350

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number5421-024
License Number StateWI

VIII. Authorized Official

Name: JOHN T O'DELL
Title or Position: OWNER
Credential: PT
Phone: 920-564-6107