Provider Demographics
NPI:1952887549
Name:COUNTRYSIDE MANOR NURSING AND REHABILITATION LLC
Entity Type:Organization
Organization Name:COUNTRYSIDE MANOR NURSING AND REHABILITATION LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ATTORNEY
Authorized Official - Prefix:
Authorized Official - First Name:HAYLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:216-706-3936
Mailing Address - Street 1:15 AMERICA AVE UNIT 304
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:08701-4582
Mailing Address - Country:US
Mailing Address - Phone:513-487-7479
Mailing Address - Fax:
Practice Address - Street 1:1865 COUNTRYSIDE DR
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:OH
Practice Address - Zip Code:43420-8748
Practice Address - Country:US
Practice Address - Phone:419-334-2602
Practice Address - Fax:419-344-6287
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-17
Last Update Date:2018-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2362N314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2362NOtherLICENSURE