Provider Demographics
NPI:1891053575
Name:COUNTRYSIDE ACRES ASSISTED LIVING
Entity Type:Organization
Organization Name:COUNTRYSIDE ACRES ASSISTED LIVING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:SARA
Authorized Official - Middle Name:JO
Authorized Official - Last Name:STADLER
Authorized Official - Suffix:
Authorized Official - Credentials:LPN
Authorized Official - Phone:715-866-4411
Mailing Address - Street 1:5788 COUNTY ROAD C
Mailing Address - Street 2:
Mailing Address - City:WEBSTER
Mailing Address - State:WI
Mailing Address - Zip Code:54893-8719
Mailing Address - Country:US
Mailing Address - Phone:715-866-4411
Mailing Address - Fax:715-866-4469
Practice Address - Street 1:5788 COUNTY ROAD C
Practice Address - Street 2:
Practice Address - City:WEBSTER
Practice Address - State:WI
Practice Address - Zip Code:54893-8719
Practice Address - Country:US
Practice Address - Phone:715-866-4411
Practice Address - Fax:715-866-4469
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-01
Last Update Date:2012-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI0013811310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility