# COUNTRYSIDE THERAPY SERVICE LLC

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1336391127
- **Authorized official:** JOHN T O'DELL PT (OWNER)
- **Authorized official phone:** (920) 564-6107

## Contact information

- **Practice address:** W4523 COUNTY ROAD IW, WALDO, WI 53093-1639
- **Practice address phone:** (920) 564-6107
- **Mailing address:** PO BOX 1127, SHEBOYGAN, WI 53082-1127
- **Mailing address phone:** (920) 457-6750
- **Mailing address fax:** (920) 457-8350

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 208100000X | Physical Medicine & Rehabilitation Physician | 5421-024 | WI | Yes |

## Other

- **Enumeration date:** 10/13/2008
- **Last updated:** 10/13/2008