MEDICARE: COUNTRYSIDE HOSPICE CARE INC

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	251G00000X	Community Based Hospice Care Agency

General Provider Information

NPI Number	:	1710925227
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COUNTRYSIDE HOSPICE CARE INC

Provider Business Mailing Address
First Line	:	101 SUN AVE NE
Second Line	:
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87109-4373
Country	:	US
Telephone Number	:	505-468-5604
Fax Number	:	505-468-4681

Provider Business Practice Location Address
First Line	:	3355 HIGHWAY 431
Second Line	:	SUITE 3
City	:	ROANOKE
State	:	AL
Zip	:	36274-2723
Country	:	US
Telephone Number	:	334-863-4984
Fax Number	:	334-863-4999

Authorized Official
Title or Position	:	SR. VP - OPERATIONS
Name	:	MR. GLEN CAVALLO
Credential	:
Telephone Number	:	479-996-5900

Provider Enumeration Date	:	06/04/2006
Last Update Date	:	01/26/2011

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