Basic Information
| Provider Information | |||||||||
| NPI: | 1225029879 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COUNTRY HEALTH, INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | COUNTRY HEALTH CARE & REHAB | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 2304 COUNTY ROAD 3000 N | ||||||||
| Address2: | |||||||||
| City: | GIFFORD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 618479756 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2175687362 | ||||||||
| FaxNumber: | 2175687314 | ||||||||
| Practice Location | |||||||||
| Address1: | 2304 COUNTY ROAD 3000 N | ||||||||
| Address2: | |||||||||
| City: | GIFFORD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 618479756 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2175687362 | ||||||||
| FaxNumber: | 2175687314 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/02/2005 | ||||||||
| LastUpdateDate: | 05/27/2014 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | UNDERWOOD | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | SR. VP & CFO | ||||||||
| AuthorizedOfficialTelephone: | 3098237135 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 0007880 | IL | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
No ID Information.