Provider Demographics
NPI:1114024213
Name:FAITH COUNTRYSIDE HOMES
Entity Type:Organization
Organization Name:FAITH COUNTRYSIDE HOMES
Other - Org Name:FAITH CARE CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:GERALD
Authorized Official - Middle Name:
Authorized Official - Last Name:HARMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-654-4600
Mailing Address - Street 1:100 FAITH DR
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND
Mailing Address - State:IL
Mailing Address - Zip Code:62249-2638
Mailing Address - Country:US
Mailing Address - Phone:618-654-4600
Mailing Address - Fax:618-654-4604
Practice Address - Street 1:100 FAITH DR
Practice Address - Street 2:
Practice Address - City:HIGHLAND
Practice Address - State:IL
Practice Address - Zip Code:62249-2638
Practice Address - Country:US
Practice Address - Phone:618-654-4600
Practice Address - Fax:618-654-4604
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2010-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0044552314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========002Medicaid
146060Medicare Oscar/Certification