Provider Demographics
NPI:1063498285
Name:COUNTRYSIDE CARE CENTRE LP
Entity Type:Organization
Organization Name:COUNTRYSIDE CARE CENTRE LP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CONTROLLER
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:CHARLES
Authorized Official - Last Name:BRAUN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-583-0100
Mailing Address - Street 1:2330 W GALENA BLVD
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:IL
Mailing Address - Zip Code:60506-4246
Mailing Address - Country:US
Mailing Address - Phone:630-896-4686
Mailing Address - Fax:630-896-7868
Practice Address - Street 1:2330 W GALENA BLVD
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:IL
Practice Address - Zip Code:60506-4246
Practice Address - Country:US
Practice Address - Phone:630-896-4686
Practice Address - Fax:630-896-7868
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-20
Last Update Date:2012-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL40931314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL40931OtherIDPH LICENSE NUMBER
IL6002174OtherIDPH FACILITY NUMBER
IL=========001Medicaid
IL6002174OtherIDPH FACILITY NUMBER