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General NPI Number Information
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NPI Number | 1396103685
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Entity Type | Organization
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Legal Business Name | COUNTRYSIDE MEDICAL CLINIC, LLC
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Dates
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Enumeration Date | 02/02/2016
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Last Update Date | 12/12/2018
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Provider Practice Location Address
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Address Line | 1959 200TH ST
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City | RED OAK
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State | IA
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Zip | 51566-3218
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Country | US
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Telephone | 712-629-0040
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Fax | 712-566-5049
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Provider Business Mailing Address
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Address Line | 1959 200TH ST
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City | RED OAK
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State | IA
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Zip | 51566-3218
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Country | US
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Telephone | 712-629-0040
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Fax | 712-566-5049
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Authorized Official
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Title or Position | NURSE PRACTITIONER
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Name | MS. KIMBERLY LYNN RINES
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Credential | ARNP
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Telephone | 712-629-0040
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2300X
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Taxonomy Name | Primary Care Clinic/Center
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License Number |
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License Number State |
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