Organization
COUNTRYSIDE HOSPICE CARE INC
Active
Parent organization
COUNTRYSIDE HOSPICE CARE INC
Other names
SolAmor Hospice Lafayette
Organization subpart
Yes
Provider details
NPI number
Legal business name
COUNTRYSIDE HOSPICE CARE INC
Authorized official
MR. GLEN CAVALLO (SR. VP - OPERATIONS)
(479) 996-5900
Entity
Organization
Contact information
Practice address
106 PEARL DR, SUITE 107, LA FAYETTE, GA 30728-7509
(706) 638-7651
(706) 638-7545
Mailing address
101 SUN AVE NE, ALBUQUERQUE, NM 87109-4373
(505) 468-5604
(505) 468-4681
Taxonomy
Speciality
Code
Description
License number
State
251G00000X
Community Based Hospice Care Agency
Primary
146142H
GA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
00850044A
—
GA
01
—
146142H
GEORGIA HOSPICE LICENSE
GA
Enumeration date
06/03/2006
Last updated
02/16/2012
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