Basic Information
| Provider Information | |||||||||
| NPI: | 1972003721 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COUNTRYSIDE CENTER FOR REHABILITATION AND NURSING, LLC | ||||||||
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| OtherOrganizationName: | COUNTRYSIDE CENTER FOR REHABILITATION AND NURSING | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 212 2ND ST STE 501 | ||||||||
| Address2: | |||||||||
| City: | LAKEWOOD | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 087013424 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7324971150 | ||||||||
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| Practice Location | |||||||||
| Address1: | 47 MARGO AVE | ||||||||
| Address2: | |||||||||
| City: | BARDWELL | ||||||||
| State: | KY | ||||||||
| PostalCode: | 420239005 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2706285424 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/19/2018 | ||||||||
| LastUpdateDate: | 11/06/2018 | ||||||||
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| AuthorizedOfficialLastName: | HERBSTMAN | ||||||||
| AuthorizedOfficialFirstName: | MOSHE | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 7324971150 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 311ZA0620X | KY | N | Nursing & Custodial Care Facilities | Custodial Care Facility | Adult Care Home | 385H00000X | KY | N | Respite Care Facility | Respite Care | 314000000X | KY | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
No ID Information.