1265470249 NPI number — COUNTRYSIDE HOSPICE CARE INC

Table of content: (NPI 1265470249)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265470249 NPI number — COUNTRYSIDE HOSPICE CARE INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COUNTRYSIDE HOSPICE CARE INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
SOLAMOR HOSPICE LAFAYETTE
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1265470249
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/16/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
101 SUN AVE NE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ALBUQUERQUE
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87109-4373
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-468-5604
Provider Business Mailing Address Fax Number:
505-468-4681

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
106 PEARL DR
Provider Second Line Business Practice Location Address:
SUITE 107
Provider Business Practice Location Address City Name:
LA FAYETTE
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30728-7509
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
706-638-7651
Provider Business Practice Location Address Fax Number:
706-638-7545
Provider Enumeration Date:
06/03/2006

Additional Information

Authorized Official

Authorized Official Last Name:
CAVALLO
Authorized Official First Name:
GLEN
Authorized Official Middle Name:
Authorized Official Title or Position:
SR. VP - OPERATIONS
Authorized Official Telephone Number:
479-996-5900

Provider Taxonomy Codes

  • Taxonomy code: 251G00000X , with the licence number:  146142H , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 00850044A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 146142H . This is a "GEORGIA HOSPICE LICENSE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com