Provider Demographics
NPI:1750497830
Name:COUNTRYSIDE BIRTHING PLACE INC
Entity Type:Organization
Organization Name:COUNTRYSIDE BIRTHING PLACE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPERATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHIRLEY
Authorized Official - Middle Name:J
Authorized Official - Last Name:TREGILLUS
Authorized Official - Suffix:
Authorized Official - Credentials:LM
Authorized Official - Phone:727-796-7502
Mailing Address - Street 1:3060 JONES LN
Mailing Address - Street 2:
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33759-1603
Mailing Address - Country:US
Mailing Address - Phone:727-796-7502
Mailing Address - Fax:727-796-7072
Practice Address - Street 1:3060 JONES LN
Practice Address - Street 2:
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33759-1603
Practice Address - Country:US
Practice Address - Phone:727-796-7502
Practice Address - Fax:727-796-7072
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-22
Last Update Date:2014-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL337261QB0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QB0400XAmbulatory Health Care FacilitiesClinic/CenterBirthingGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL011140400Medicaid