MEDICARE: COUNTRYSIDE LIVING

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	310400000X	Assisted Living Facility	HAL-096-018	NC

General Provider Information

NPI Number	:	1184829038
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COUNTRYSIDE LIVING

Provider Business Mailing Address
First Line	:	PO BOX 335
Second Line	:
City	:	PIKEVILLE
State	:	NC
Zip	:	27863-0335
Country	:	US
Telephone Number	:	919-242-6369
Fax Number	:	919-242-9884

Provider Business Practice Location Address
First Line	:	5383 US 117 NORTH
Second Line	:
City	:	PIKEVILLE
State	:	NC
Zip	:	27863-0335
Country	:	US
Telephone Number	:	919-242-6369
Fax Number	:	919-242-9884

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MRS. MARSHA OVERMAN SAULS
Credential	:
Telephone Number	:	919-242-6369

Provider Enumeration Date	:	06/20/2007
Last Update Date	:	08/22/2020

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Directions to “COUNTRYSIDE LIVING ” Practice Location

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