=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275571259
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COUNTRYSIDE HOSPICE CARE INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/03/2006
-----------------------------------------------------
Last Update Date | 05/20/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 955 S THREE NOTCH ST
-----------------------------------------------------
City | ANDALUSIA
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 36420-5231
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 334-222-7048
-----------------------------------------------------
Fax | 334-427-7246
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1021 NOBLE ST SUITE 207
-----------------------------------------------------
City | ANNISTON
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 36201-4607
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 256-231-9190
-----------------------------------------------------
Fax | 256-231-9190
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT CEO
-----------------------------------------------------
Name | MS. NANCY C JAKUS
-----------------------------------------------------
Credential | BSN MBA RN
-----------------------------------------------------
Telephone | 256-231-9190
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251G00000X
-----------------------------------------------------
Taxonomy Name | Community Based Hospice Care Agency
-----------------------------------------------------
License Number | 11636
-----------------------------------------------------
License Number State | AL
-----------------------------------------------------