Provider Demographics
NPI:1043520133
Name:COUNTRYSIDE HOME, LLC
Entity Type:Organization
Organization Name:COUNTRYSIDE HOME, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:KAY
Authorized Official - Last Name:HOWLETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:417-532-7418
Mailing Address - Street 1:24499 PARK DR
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:MO
Mailing Address - Zip Code:65536-5843
Mailing Address - Country:US
Mailing Address - Phone:417-532-7418
Mailing Address - Fax:417-532-9359
Practice Address - Street 1:24499 PARK DR
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:MO
Practice Address - Zip Code:65536-5843
Practice Address - Country:US
Practice Address - Phone:417-532-7418
Practice Address - Fax:417-532-9359
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-07
Last Update Date:2010-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility