Basic Information
| Provider Information | |||||||||
| NPI: | 1639117690 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COUNTRYSIDE HOSPICE CARE INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | SOLAMOR HOSPICE SHARPSBURG | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 101 SUN AVE NE | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871094373 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5054685604 | ||||||||
| FaxNumber: | 5054684681 | ||||||||
| Practice Location | |||||||||
| Address1: | 820 EBENEZER CHURCH RD | ||||||||
| Address2: | SUITE 106 | ||||||||
| City: | SHARPSBURG | ||||||||
| State: | GA | ||||||||
| PostalCode: | 302772073 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7702524999 | ||||||||
| FaxNumber: | 7702524743 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/03/2006 | ||||||||
| LastUpdateDate: | 02/16/2012 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| AuthorizedOfficialLastName: | CAVALLO | ||||||||
| AuthorizedOfficialFirstName: | GLEN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | SR. VP - OPERATIONS | ||||||||
| AuthorizedOfficialTelephone: | 4799965900 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251G00000X | 038156H | GA | Y | Agencies | Hospice Care, Community Based |
ID Information
| ID | Type | State | Issuer | Description | 00894132A | 05 | GA | MEDICAID | 038156H | 01 | GA | GEORGIA HOSPICE LICENSE | OTHER |