Provider Demographics
NPI:1790433118
Name:COUNTRYSIDE LIVING & ELDERY HOME CARE
Entity Type:Organization
Organization Name:COUNTRYSIDE LIVING & ELDERY HOME CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TIM
Authorized Official - Middle Name:KEITH
Authorized Official - Last Name:FLEENOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:937-875-0490
Mailing Address - Street 1:307 BEECHGROVE DR
Mailing Address - Street 2:
Mailing Address - City:ENGLEWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:45322-1105
Mailing Address - Country:US
Mailing Address - Phone:937-432-9870
Mailing Address - Fax:937-432-9871
Practice Address - Street 1:307 BEECHGROVE DR
Practice Address - Street 2:
Practice Address - City:ENGLEWOOD
Practice Address - State:OH
Practice Address - Zip Code:45322-1105
Practice Address - Country:US
Practice Address - Phone:937-432-9870
Practice Address - Fax:937-432-9871
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-03-15
Last Update Date:2022-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health