Provider Demographics
NPI:1295029791
Name:COUNTRYSIDE VILLAGE LLC
Entity Type:Organization
Organization Name:COUNTRYSIDE VILLAGE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:CHRYLL
Authorized Official - Last Name:BATEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-917-4799
Mailing Address - Street 1:3505 PRIMROSE AVE
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27408-3192
Mailing Address - Country:US
Mailing Address - Phone:336-617-4799
Mailing Address - Fax:336-617-4799
Practice Address - Street 1:5383 US HIGHWAY 117 N
Practice Address - Street 2:
Practice Address - City:PIKEVILLE
Practice Address - State:NC
Practice Address - Zip Code:27863-9443
Practice Address - Country:US
Practice Address - Phone:919-242-6369
Practice Address - Fax:919-242-9884
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-02
Last Update Date:2011-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility