Provider Demographics
NPI:1265470249
Name:COUNTRYSIDE HOSPICE CARE INC
Entity Type:Organization
Organization Name:COUNTRYSIDE HOSPICE CARE INC
Other - Org Name:SOLAMOR HOSPICE LAFAYETTE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SR. VP - OPERATIONS
Authorized Official - Prefix:MR
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 1:106 PEARL DR
Practice Address - Street 2:SUITE 107
Practice Address - City:LA FAYETTE
Practice Address - State:GA
Practice Address - Zip Code:30728-7509
Practice Address - Country:US
Practice Address - Phone:706-638-7651
Practice Address - Fax:706-638-7545
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COUNTRYSIDE HOSPICE CARE INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-06-03
Last Update Date:2012-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA146142H251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00850044AMedicaid
GA146142HOtherGEORGIA HOSPICE LICENSE
GA00850044AMedicaid