Provider Demographics
NPI:1790723211
Name:COUNTRYSIDE HOSPICE CARE INC
Entity Type:Organization
Organization Name:COUNTRYSIDE HOSPICE CARE INC
Other - Org Name:SOLAMORE HOSPICE JACKSONVILLE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SR. VP OF 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 1:320 BRANSCOMB DR SW
Practice Address - Street 2:SUITE D
Practice Address - City:JACKSONVILLE
Practice Address - State:AL
Practice Address - Zip Code:36265
Practice Address - Country:US
Practice Address - Phone:256-235-2999
Practice Address - Fax:256-782-3590
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SOLAMOR HOSPICE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-06-04
Last Update Date:2011-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALPIC1579EMedicaid
AL011579Medicare ID - Type Unspecified