Provider Demographics
NPI:1295028389
Name:COUNTRYSIDE ASSISTED LIVING, LLC
Entity Type:Organization
Organization Name:COUNTRYSIDE ASSISTED LIVING, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:TARA
Authorized Official - Middle Name:H
Authorized Official - Last Name:BOX
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:479-738-1500
Mailing Address - Street 1:722 PHILLIPS PL
Mailing Address - Street 2:
Mailing Address - City:HUNTSVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72740-9517
Mailing Address - Country:US
Mailing Address - Phone:479-738-1500
Mailing Address - Fax:479-738-1000
Practice Address - Street 1:722 PHILLIPS PL
Practice Address - Street 2:
Practice Address - City:HUNTSVILLE
Practice Address - State:AR
Practice Address - Zip Code:72740-9517
Practice Address - Country:US
Practice Address - Phone:479-738-1500
Practice Address - Fax:479-738-1000
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-23
Last Update Date:2011-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR037310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility