Provider Demographics
NPI:1508136862
Name:COUNTRYSIDE HOSPICE CARE, INC.
Entity Type:Organization
Organization Name:COUNTRYSIDE HOSPICE CARE, INC.
Other - Org Name:COUNTRYSIDE HOSPICE-DECATUR
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CORPORATE SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:T
Authorized Official - Last Name:BERG
Authorized Official - Suffix:
Authorized Official - Credentials:JD
Authorized Official - Phone:505-821-3355
Mailing Address - Street 1:18831 VON KARMAN BLVD.
Mailing Address - Street 2:SUITE 400
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92612-1533
Mailing Address - Country:US
Mailing Address - Phone:949-255-7129
Mailing Address - Fax:505-468-9250
Practice Address - Street 1:801 CHURCH STREET NE
Practice Address - Street 2:SUITES 6 AND 7
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:35601-2400
Practice Address - Country:US
Practice Address - Phone:256-432-2718
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-04
Last Update Date:2012-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL01-1579PSL251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALPIC1579EPSLMedicaid