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General NPI Number Information
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NPI Number | 1336135318
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Entity Type | Organization
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Legal Business Name | COUNTRYSIDE HOME CARE, INC
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Dates
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Enumeration Date | 09/23/2005
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 1213 MAIN ST
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City | SALMON
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State | ID
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Zip | 83467-4324
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Country | US
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Telephone | 208-756-4032
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Fax | 208-756-6477
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Provider Business Mailing Address
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Address Line | 1213 MAIN ST
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City | SALMON
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State | ID
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Zip | 83467-4324
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Country | US
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Telephone | 208-756-4032
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Fax | 208-756-6477
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Authorized Official
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Title or Position | OWNER/ADMINISTRATOR
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Name | JOHN GROVER
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Credential |
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Telephone | 208-756-4032
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251E00000X
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Taxonomy Name | Home Health Agency
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License Number |
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License Number State |
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