Provider Demographics
NPI:1902881022
Name:COUNTRYSIDE HOME
Entity Type:Organization
Organization Name:COUNTRYSIDE HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:ADMINISTRATOR
Authorized Official - Phone:402-454-3373
Mailing Address - Street 1:703 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:NE
Mailing Address - Zip Code:68748-6009
Mailing Address - Country:US
Mailing Address - Phone:402-454-3373
Mailing Address - Fax:402-454-6509
Practice Address - Street 1:703 N MAIN ST
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:NE
Practice Address - Zip Code:68748-6009
Practice Address - Country:US
Practice Address - Phone:402-454-3373
Practice Address - Fax:402-454-6509
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-13
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE0637150001OtherMEDICARE DME
NE0637150001OtherMEDICARE DME
NE285207Medicare Oscar/Certification