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General NPI Number Information
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NPI Number | 1952887549
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Entity Type | Organization
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Legal Business Name | COUNTRYSIDE MANOR NURSING AND REHABILITATION LLC
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Dates
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Enumeration Date | 07/17/2018
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Last Update Date | 07/17/2018
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Provider Practice Location Address
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Address Line | 1865 COUNTRYSIDE DR
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City | FREMONT
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State | OH
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Zip | 43420-8748
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Country | US
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Telephone | 419-334-2602
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Fax | 419-344-6287
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Provider Business Mailing Address
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Address Line | 15 AMERICA AVE UNIT 304
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City | LAKEWOOD
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State | NJ
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Zip | 08701-4582
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Country | US
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Telephone | 513-487-7479
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Fax |
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Authorized Official
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Title or Position | ATTORNEY
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Name | HAYLEY WILLIAMS
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Credential |
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Telephone | 216-706-3936
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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 | 2362N
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License Number State | OH
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