Provider Demographics
NPI:1922139096
Name:COUNTRYSIDE HOME INC
Entity Type:Organization
Organization Name:COUNTRYSIDE HOME INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER OPERATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:PAM
Authorized Official - Middle Name:J
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:785-263-7197
Mailing Address - Street 1:2454 HWY 15 NORTH
Mailing Address - Street 2:
Mailing Address - City:ABILENE
Mailing Address - State:KS
Mailing Address - Zip Code:67410-6084
Mailing Address - Country:US
Mailing Address - Phone:785-263-7197
Mailing Address - Fax:785-263-9885
Practice Address - Street 1:2454 HWY 15 NORTH
Practice Address - Street 2:
Practice Address - City:ABILENE
Practice Address - State:KS
Practice Address - Zip Code:67410-6084
Practice Address - Country:US
Practice Address - Phone:785-263-7197
Practice Address - Fax:785-263-9885
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KSN021006310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility