Provider Demographics
NPI:1326035445
Name:COUNTRYSIDE NURSING HOME, INC
Entity Type:Organization
Organization Name:COUNTRYSIDE NURSING HOME, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:L
Authorized Official - Last Name:STEACIE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:508-872-5250
Mailing Address - Street 1:153 WINTER ST
Mailing Address - Street 2:
Mailing Address - City:FRAMINGHAM
Mailing Address - State:MA
Mailing Address - Zip Code:01702-2433
Mailing Address - Country:US
Mailing Address - Phone:508-872-5250
Mailing Address - Fax:508-872-1217
Practice Address - Street 1:153 WINTER ST
Practice Address - Street 2:
Practice Address - City:FRAMINGHAM
Practice Address - State:MA
Practice Address - Zip Code:01702-2433
Practice Address - Country:US
Practice Address - Phone:508-872-5250
Practice Address - Fax:508-872-1217
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA0367313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0901547Medicaid