Provider Demographics
NPI:1275673642
Name:COUNTRYSIDE MANOR LLC
Entity Type:Organization
Organization Name:COUNTRYSIDE MANOR LLC
Other - Org Name:COUNTRYSIDE MANOR
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:PRICE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-967-9285
Mailing Address - Street 1:300 S THOMPSON RD
Mailing Address - Street 2:
Mailing Address - City:LAMAR
Mailing Address - State:AR
Mailing Address - Zip Code:72846-9423
Mailing Address - Country:US
Mailing Address - Phone:479-754-2052
Mailing Address - Fax:479-754-5745
Practice Address - Street 1:300 S THOMPSON RD
Practice Address - Street 2:
Practice Address - City:LAMAR
Practice Address - State:AR
Practice Address - Zip Code:72846-9423
Practice Address - Country:US
Practice Address - Phone:479-754-2052
Practice Address - Fax:479-754-5745
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-07
Last Update Date:2008-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
045168Medicare Oscar/Certification