Provider Demographics
NPI:1245562107
Name:COUNTRYSIDE HOSPICE CARE, INC
Entity Type:Organization
Organization Name:COUNTRYSIDE HOSPICE CARE, INC
Other - Org Name:SOLAMOR HOSPICE CALHOUN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SR. VP - OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:GLEN
Authorized Official - Middle Name:
Authorized Official - Last Name:CAVALLO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:479-996-5900
Mailing Address - Street 1:101 SUN AVE NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87109-4373
Mailing Address - Country:US
Mailing Address - Phone:505-468-5604
Mailing Address - Fax:505-468-4681
Practice Address - Street 1:189 PROFESSIONAL CT SE
Practice Address - Street 2:SUITE 300
Practice Address - City:CALHOUN
Practice Address - State:GA
Practice Address - Zip Code:30701-7053
Practice Address - Country:US
Practice Address - Phone:706-602-9001
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-03
Last Update Date:2012-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA146-142-H251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based