Provider Demographics
NPI:1275571259
Name:COUNTRYSIDE HOSPICE CARE INC
Entity Type:Organization
Organization Name:COUNTRYSIDE HOSPICE CARE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:NANCY
Authorized Official - Middle Name:C
Authorized Official - Last Name:JAKUS
Authorized Official - Suffix:
Authorized Official - Credentials:BSN MBA RN
Authorized Official - Phone:256-231-9190
Mailing Address - Street 1:1021 NOBLE ST
Mailing Address - Street 2:SUITE 207
Mailing Address - City:ANNISTON
Mailing Address - State:AL
Mailing Address - Zip Code:36201-4607
Mailing Address - Country:US
Mailing Address - Phone:256-231-9190
Mailing Address - Fax:256-231-9190
Practice Address - Street 1:955 S THREE NOTCH ST
Practice Address - Street 2:
Practice Address - City:ANDALUSIA
Practice Address - State:AL
Practice Address - Zip Code:36420-5231
Practice Address - Country:US
Practice Address - Phone:334-222-7048
Practice Address - Fax:334-427-7246
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:2008-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL11636251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL11636OtherALABAMA HOSPICE LICENSE
ALPIC1547EMedicaid
ALPIC1547EMedicaid