Provider Demographics
NPI: | 1619914082 |
---|---|
Name: | COUNTRYSIDE HOSPICE CARE INC |
Entity Type: | Organization |
Organization Name: | COUNTRYSIDE HOSPICE CARE INC |
Other - Org Name: | COUNTRYSIDE HOSPICE BIRMINGHAM |
Other - Org Type: | Doing Business As |
Authorized Official - Title/Position: | SR. VP - OPERATIONS |
Authorized Official - Prefix: | MR |
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: | 101 SUN AVE NE |
Mailing Address - Street 2: | |
Mailing Address - City: | ALBUQUERQUE |
Mailing Address - State: | NM |
Mailing Address - Zip Code: | 87109-4373 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 505-468-5604 |
Mailing Address - Fax: | 505-468-4681 |
Practice Address - Street 1: | 13521 SHELBY COUNTY 280 |
Practice Address - Street 2: | SUITE 253 |
Practice Address - City: | BIRMINGHAM |
Practice Address - State: | AL |
Practice Address - Zip Code: | 35242 |
Practice Address - Country: | US |
Practice Address - Phone: | 205-991-9091 |
Practice Address - Fax: | |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | Yes |
Parent Organization LBN: | COUNTRYSIDE HOSPICE CARE INC |
Parent Organization TIN: | <UNAVAIL> |
Enumeration Date: | 2006-06-02 |
Last Update Date: | 2011-01-28 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 251G00000X | Agencies | Hospice Care, Community Based |