Provider Demographics
NPI:1164597688
Name:COUNTRYSIDE CARE CENTER, INC.
Entity Type:Organization
Organization Name:COUNTRYSIDE CARE CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:GANTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:517-787-4150
Mailing Address - Street 1:2121 ROBINSON RD
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49203-3658
Mailing Address - Country:US
Mailing Address - Phone:517-787-4150
Mailing Address - Fax:
Practice Address - Street 1:2121 ROBINSON RD
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49203-3658
Practice Address - Country:US
Practice Address - Phone:517-787-4150
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-21
Last Update Date:2023-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI38-4180314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2153813Medicaid
MI235574Medicare ID - Type Unspecified