Provider Demographics
NPI:1356300206
Name:COUNTRYSIDE MANOR HEALTHCARE CENTER
Entity Type:Organization
Organization Name:COUNTRYSIDE MANOR HEALTHCARE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:HERVEY
Authorized Official - Middle Name:
Authorized Official - Last Name:LAWRENCE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:765-649-4558
Mailing Address - Street 1:205 MARINE DR
Mailing Address - Street 2:
Mailing Address - City:ANDERSON
Mailing Address - State:IN
Mailing Address - Zip Code:46016-5937
Mailing Address - Country:US
Mailing Address - Phone:765-649-4558
Mailing Address - Fax:765-641-1239
Practice Address - Street 1:205 MARINE DR
Practice Address - Street 2:
Practice Address - City:ANDERSON
Practice Address - State:IN
Practice Address - Zip Code:46016-5937
Practice Address - Country:US
Practice Address - Phone:765-649-4558
Practice Address - Fax:765-641-1239
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3140N1450XNursing & Custodial Care FacilitiesSkilled Nursing FacilityNursing Care, Pediatric
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN155258Medicare ID - Type Unspecified