Provider Demographics
NPI:1518238286
Name:COUNTRYSIDE HOSPICE CARE, INC
Entity Type:Organization
Organization Name:COUNTRYSIDE HOSPICE CARE, INC
Other - Org Name:SOLAMOR HOSPICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SR. VP - OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:GLEN
Authorized Official - Middle Name:
Authorized Official - Last Name:CAVALLO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:479-996-5900
Mailing Address - Street 1:3522 VANN RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35235-3224
Mailing Address - Country:US
Mailing Address - Phone:205-655-2229
Mailing Address - Fax:205-655-3031
Practice Address - Street 1:101 SUN AVE NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-4373
Practice Address - Country:US
Practice Address - Phone:505-468-5604
Practice Address - Fax:505-468-4681
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-26
Last Update Date:2012-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALE3735251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL011579Medicare UPIN