Basic Information
| Provider Information | |||||||||
| NPI: | 1104825876 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COUNTRYSIDE RETIREMENT HOME OF SIOUX CITY, IOWA | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | COUNTRYSIDE RETIREMENT HOME, INC. | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6120 MORNINGSIDE AVE | ||||||||
| Address2: | |||||||||
| City: | SIOUX CITY | ||||||||
| State: | IA | ||||||||
| PostalCode: | 511063943 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7122763000 | ||||||||
| FaxNumber: | 7122662167 | ||||||||
| Practice Location | |||||||||
| Address1: | 6120 MORNINGSIDE AVE | ||||||||
| Address2: | |||||||||
| City: | SIOUX CITY | ||||||||
| State: | IA | ||||||||
| PostalCode: | 511063943 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7122763000 | ||||||||
| FaxNumber: | 7122662167 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/15/2005 | ||||||||
| LastUpdateDate: | 09/11/2009 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MENZENBERG | ||||||||
| AuthorizedOfficialFirstName: | DEBBIE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 7122763000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 311Z00000X | R-0370 | IA | N | Nursing & Custodial Care Facilities | Custodial Care Facility | 313M00000X | N-0370 | IA | Y | Nursing & Custodial Care Facilities | Nursing Facility/Intermediate Care Facility |
ID Information
| ID | Type | State | Issuer | Description | 0800300 | 05 | IA | MEDICAID |