Provider Demographics
NPI:1386966919
Name:COUNTRYSIDE NURSING AND REHABILITATION CENTER LLC
Entity type:Organization
Organization Name:COUNTRYSIDE NURSING AND REHABILITATION CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JOE
Authorized Official - Middle Name:
Authorized Official - Last Name:ZIMMERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-905-4000
Mailing Address - Street 1:1635 E 154TH ST
Mailing Address - Street 2:
Mailing Address - City:DOLTON
Mailing Address - State:IL
Mailing Address - Zip Code:60419-3001
Mailing Address - Country:US
Mailing Address - Phone:708-841-9550
Mailing Address - Fax:708-841-4517
Practice Address - Street 1:1635 E 154TH ST
Practice Address - Street 2:
Practice Address - City:DOLTON
Practice Address - State:IL
Practice Address - Zip Code:60419-3001
Practice Address - Country:US
Practice Address - Phone:708-841-9550
Practice Address - Fax:708-841-4517
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-24
Last Update Date:2010-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0050708314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========001Medicaid
IL=========001Medicaid