Basic Information
| Provider Information | |||||||||
| NPI: | 1598096356 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | EMERICARE INC | ||||||||
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| OtherOrganizationName: | COUNTRYSIDE HEALTH CARE CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3131 ELLIOTT AVE | ||||||||
| Address2: | SUITE 500 | ||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981211044 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2062982909 | ||||||||
| FaxNumber: | 2063014500 | ||||||||
| Practice Location | |||||||||
| Address1: | 706 PELZER HWY | ||||||||
| Address2: | |||||||||
| City: | EASLEY | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296422941 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8648590167 | ||||||||
| FaxNumber: | 8648592312 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/19/2010 | ||||||||
| LastUpdateDate: | 01/19/2010 | ||||||||
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| AuthorizedOfficialLastName: | BICKEL | ||||||||
| AuthorizedOfficialFirstName: | NOELLE | ||||||||
| AuthorizedOfficialMiddleName: | DIAZ | ||||||||
| AuthorizedOfficialTitleorPosition: | LICENSING SPECIALIST | ||||||||
| AuthorizedOfficialTelephone: | 2062982909 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | EMERICAL INC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | NCF-0701 | SC | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
No ID Information.