Provider Demographics
NPI:1386208270
Name:SOUTHSIDE GROUP HOMES, LLC
Entity Type:Organization
Organization Name:SOUTHSIDE GROUP HOMES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:ILAPIT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-362-1479
Mailing Address - Street 1:3400 AIRLINE BLVD
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:VA
Mailing Address - Zip Code:23701-2623
Mailing Address - Country:US
Mailing Address - Phone:757-673-1483
Mailing Address - Fax:757-405-6326
Practice Address - Street 1:3400 AIRLINE BLVD
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:VA
Practice Address - Zip Code:23701-2623
Practice Address - Country:US
Practice Address - Phone:757-673-1483
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-04-25
Last Update Date:2019-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0610652114Medicaid
VA0730265045Medicaid
VA0173726701Medicaid
VA0243633416Medicaid