Basic Information
| Provider Information | |||||||||
| NPI: | 1275673642 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COUNTRYSIDE MANOR LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | COUNTRYSIDE MANOR | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 300 S THOMPSON RD | ||||||||
| Address2: | |||||||||
| City: | LAMAR | ||||||||
| State: | AR | ||||||||
| PostalCode: | 728469423 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4797542052 | ||||||||
| FaxNumber: | 4797545745 | ||||||||
| Practice Location | |||||||||
| Address1: | 300 S THOMPSON RD | ||||||||
| Address2: | |||||||||
| City: | LAMAR | ||||||||
| State: | AR | ||||||||
| PostalCode: | 728469423 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4797542052 | ||||||||
| FaxNumber: | 4797545745 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/07/2007 | ||||||||
| LastUpdateDate: | 02/19/2008 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | PRICE | ||||||||
| AuthorizedOfficialFirstName: | JUSTIN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | MEMBER | ||||||||
| AuthorizedOfficialTelephone: | 9189679285 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 313M00000X | AR | Y | Nursing & Custodial Care Facilities | Nursing Facility/Intermediate Care Facility |
No ID Information.