| Organization Name: | COUNTRYSIDE HOSPICE CARE, INC |
| NPI Number: | 1093086811 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | GLEN CAVALLO (SR. VP - OPERATIONS) |
| Mailing Address: | 105 Corporate Plaza Dr Lagrange |
| State: | GA US |
| Postal Code: | 302412801 |
| Phone Number: | 7068458755 |
| Fax Number: | 7068458757 |
| NPI Enumeration Date: | 01/25/2012 |
| NPI Last Update Date: | 02/16/2012 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 251G00000X |
| License Number: | 038-156H |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | GA |
| Taxonomy Type: | Agencies |
| Taxonomy Classification: | Hospice Care, Community Based |
| Taxonomy Specialization: | |
| Taxonomy Definition: | |