Basic Information
| Provider Information | |||||||||
| NPI: | 1497753834 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ATRIUM COUNTRYSIDE LLC | ||||||||
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| OtherOrganizationName: | COUNTRYSIDE NURSING AND REHABILITATION COMMUNITY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5000 HAKES DR | ||||||||
| Address2: | SUITE 600 | ||||||||
| City: | NORTON SHORES | ||||||||
| State: | MI | ||||||||
| PostalCode: | 494415574 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2317996870 | ||||||||
| FaxNumber: | 2317990250 | ||||||||
| Practice Location | |||||||||
| Address1: | 120 BASELINE RD | ||||||||
| Address2: | |||||||||
| City: | SOUTH HAVEN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490901037 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2696378411 | ||||||||
| FaxNumber: | 2696378460 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/11/2005 | ||||||||
| LastUpdateDate: | 02/13/2014 | ||||||||
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| AuthorizedOfficialLastName: | LOCKHART | ||||||||
| AuthorizedOfficialFirstName: | DENNIS | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHIEF ACCOUNTING OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 6144160600 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 80-4050 | MI | N | Nursing & Custodial Care Facilities | Skilled Nursing Facility | 310400000X | AH800236748 | MI | Y | Nursing & Custodial Care Facilities | Assisted Living Facility |
ID Information
| ID | Type | State | Issuer | Description | S 9517 | 01 | MI | BCBS PROVIDER CODE | OTHER | 60 4191457 | 05 | MI | MEDICAID |