Basic Information
| Provider Information | |||||||||
| NPI: | 1952887549 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COUNTRYSIDE MANOR NURSING AND REHABILITATION LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 15 AMERICA AVE UNIT 304 | ||||||||
| Address2: | |||||||||
| City: | LAKEWOOD | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 087014582 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5134877479 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1865 COUNTRYSIDE DR | ||||||||
| Address2: | |||||||||
| City: | FREMONT | ||||||||
| State: | OH | ||||||||
| PostalCode: | 434208748 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4193342602 | ||||||||
| FaxNumber: | 4193446287 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2018 | ||||||||
| LastUpdateDate: | 07/17/2018 | ||||||||
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| AuthorizedOfficialLastName: | WILLIAMS | ||||||||
| AuthorizedOfficialFirstName: | HAYLEY | ||||||||
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| AuthorizedOfficialTitleorPosition: | ATTORNEY | ||||||||
| AuthorizedOfficialTelephone: | 2167063936 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 2362N | OH | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 2362N | 01 | OH | LICENSURE | OTHER |