Provider Demographics
NPI:1376081323
Name:WHITESIDE MANOR, INC.
Entity Type:Organization
Organization Name:WHITESIDE MANOR, INC.
Other - Org Name:WILSHIRE HOUSE
Other - Org Type:Other Name
Authorized Official - Title/Position:ADMIN
Authorized Official - Prefix:
Authorized Official - First Name:DORI
Authorized Official - Middle Name:
Authorized Official - Last Name:DOTSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:951-788-9515
Mailing Address - Street 1:2743 ORANGE ST
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92501-2538
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2452 WILSHIRE ST
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92501-2144
Practice Address - Country:US
Practice Address - Phone:951-682-6631
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WHITESIDE MANOR, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-02-09
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility