Provider Demographics
NPI:1376537431
Name:COUNTRYSIDE CONVALESCENT HOME LIMITED PARTNERSHIP
Entity Type:Organization
Organization Name:COUNTRYSIDE CONVALESCENT HOME LIMITED PARTNERSHIP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:D
Authorized Official - Last Name:TACK
Authorized Official - Suffix:
Authorized Official - Credentials:NHA
Authorized Official - Phone:724-431-0770
Mailing Address - Street 1:8221 LAMOR RD
Mailing Address - Street 2:
Mailing Address - City:MERCER
Mailing Address - State:PA
Mailing Address - Zip Code:16137-3163
Mailing Address - Country:US
Mailing Address - Phone:724-431-0770
Mailing Address - Fax:724-431-0764
Practice Address - Street 1:8221 LAMOR RD
Practice Address - Street 2:
Practice Address - City:MERCER
Practice Address - State:PA
Practice Address - Zip Code:16137-3163
Practice Address - Country:US
Practice Address - Phone:724-431-0770
Practice Address - Fax:724-431-0764
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-06
Last Update Date:2014-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
1121OtherHIGHMARK BC
PA1501006OtherGATEWAY HP
PA0012990090001Medicaid
PA263249OtherHEALTH AMERICA
305354OtherUPMC
PA1501006OtherGATEWAY HP