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General NPI Number Information
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NPI Number | 1760415079
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Entity Type | Organization
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Legal Business Name | COUNTRYSIDE CARE CENTER CORP.
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Dates
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Enumeration Date | 07/09/2006
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Last Update Date | 10/09/2008
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Provider Practice Location Address
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Address Line | 1001 E SPRINGHILL DR
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City | TERRE HAUTE
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State | IN
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Zip | 47802-4547
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Country | US
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Telephone | 812-238-2441
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Fax | 812-299-4492
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Provider Business Mailing Address
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Address Line | 101 SUN AVE NE COMPLIANCE DEPARTMENT
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City | ALBUQUERQUE
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State | NM
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Zip | 87109-4373
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Country | US
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Telephone | 505-468-5604
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Fax | 505-468-4681
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Authorized Official
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Title or Position | PRESIDENT DIRECTOR
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Name | WILLIAM A MATHIES
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Credential |
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Telephone | 505-821-3355
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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 | 05-000119-2
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License Number State | IN
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