Provider Demographics
NPI:1598893869
Name:COUNTRYSIDE HOME
Entity Type:Organization
Organization Name:COUNTRYSIDE HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER OPERATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:CHANNITY
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:FARLEY
Authorized Official - Suffix:
Authorized Official - Credentials:REGISTEREDNURSE
Authorized Official - Phone:620-326-8749
Mailing Address - Street 1:122 S COUNTRYSIDE LN
Mailing Address - Street 2:
Mailing Address - City:WELLINGTON
Mailing Address - State:KS
Mailing Address - Zip Code:67152-8077
Mailing Address - Country:US
Mailing Address - Phone:620-326-8749
Mailing Address - Fax:620-326-2254
Practice Address - Street 1:122 S COUNTRYSIDE LN
Practice Address - Street 2:
Practice Address - City:WELLINGTON
Practice Address - State:KS
Practice Address - Zip Code:67152-8077
Practice Address - Country:US
Practice Address - Phone:620-326-8749
Practice Address - Fax:620-326-2254
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-01
Last Update Date:2008-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KSB096014311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home