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General NPI Number Information
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NPI Number | 1043520133
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Entity Type | Organization
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Legal Business Name | COUNTRYSIDE HOME, LLC
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Dates
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Enumeration Date | 10/07/2010
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Last Update Date | 10/07/2010
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Provider Practice Location Address
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Address Line | 24499 PARK DR
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City | LEBANON
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State | MO
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Zip | 65536-5843
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Country | US
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Telephone | 417-532-7418
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Fax | 417-532-9359
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Provider Business Mailing Address
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Address Line | 24499 PARK DR
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City | LEBANON
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State | MO
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Zip | 65536-5843
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Country | US
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Telephone | 417-532-7418
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Fax | 417-532-9359
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Authorized Official
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Title or Position | OWNER/ADMINISTRATOR
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Name | MS. MARY KAY HOWLETT
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Credential |
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Telephone | 417-532-7418
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 310400000X
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Taxonomy Name | Assisted Living Facility
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License Number |
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License Number State | MO
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