Provider Demographics
NPI:1568818607
Name:COUNTRYSIDE CARE CENTER, LLC
Entity Type:Organization
Organization Name:COUNTRYSIDE CARE CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:KAY
Authorized Official - Last Name:HOWLETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-855-9088
Mailing Address - Street 1:PO BOX 434
Mailing Address - Street 2:385 S. EISENHOWER ST.
Mailing Address - City:MONETT
Mailing Address - State:MO
Mailing Address - Zip Code:65708-0434
Mailing Address - Country:US
Mailing Address - Phone:417-235-4040
Mailing Address - Fax:417-235-3664
Practice Address - Street 1:385 S EISENHOWER ST
Practice Address - Street 2:
Practice Address - City:MONETT
Practice Address - State:MO
Practice Address - Zip Code:65708-8266
Practice Address - Country:US
Practice Address - Phone:417-235-4040
Practice Address - Fax:417-235-3664
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-08
Last Update Date:2016-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility