Provider Demographics
NPI:1114365657
Name:COUNTRYSIDE NURSING LLC
Entity Type:Organization
Organization Name:COUNTRYSIDE NURSING LLC
Other - Org Name:COUNTRYSIDE HEALTH CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:TOLSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-644-0471
Mailing Address - Street 1:233 CARROLLTON ST
Mailing Address - Street 2:
Mailing Address - City:BUCHANAN
Mailing Address - State:GA
Mailing Address - Zip Code:30113-4917
Mailing Address - Country:US
Mailing Address - Phone:770-646-3861
Mailing Address - Fax:770-646-3601
Practice Address - Street 1:233 CARROLLTON ST
Practice Address - Street 2:
Practice Address - City:BUCHANAN
Practice Address - State:GA
Practice Address - Zip Code:30113-4917
Practice Address - Country:US
Practice Address - Phone:770-646-3861
Practice Address - Fax:770-646-3601
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-06
Last Update Date:2013-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1-071-2017314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000141666AMedicaid
GA000141666AMedicaid