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General NPI Number Information
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NPI Number | 1386966919
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Entity Type | Organization
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Legal Business Name | COUNTRYSIDE NURSING AND REHABILITATION CENTER LLC
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Dates
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Enumeration Date | 02/24/2010
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Last Update Date | 02/24/2010
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Provider Practice Location Address
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Address Line | 1635 E 154TH ST
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City | DOLTON
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State | IL
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Zip | 60419-3001
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Country | US
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Telephone | 708-841-9550
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Fax | 708-841-4517
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Provider Business Mailing Address
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Address Line | 1635 E 154TH ST
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City | DOLTON
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State | IL
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Zip | 60419-3001
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Country | US
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Telephone | 708-841-9550
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Fax | 708-841-4517
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Authorized Official
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Title or Position | CEO
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Name | MR. JOE ZIMMERMAN
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Credential |
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Telephone | 847-905-4000
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 314000000X
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Taxonomy Name | Skilled Nursing Facility
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License Number | 0050708
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License Number State | IL
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