- Enrollment id
- O20050802000619
- Enrollment state
- OK
- Provider type code
- 00-18
- Provider type text
- PART A PROVIDER - SKILLED NURSING FACILITY
- Npi
- 1336252089
- Multiple npi flag
- N
- Ccn
- 375341
- Associate id
- 0749218584
- Organization name
- COUNTRYSIDE HEALTH SERVICES LLC
- Doing business as name
- COUNTRYSIDE ESTATES
- Incorporation date
- 2004-12-02
- Incorporation state
- OK
- Organization type structure
- LLC
- Proprietary nonprofit
- P
- Nursing home provider name
- COUNTRYSIDE ESTATES
- Address line 1
- HWY 64 EAST
- Address line 2
- COUNTRYSIDE ESTATES
- City
- WARNER
- State
- OK
- Zip code
- 744690749