Provider Demographics
NPI:1386838316
Name:WESTSIDE RESIDENTIAL
Entity Type:Organization
Organization Name:WESTSIDE RESIDENTIAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/OWNER
Authorized Official - Prefix:MISS
Authorized Official - First Name:SHAWNTAY
Authorized Official - Middle Name:CORISHA
Authorized Official - Last Name:OLIVER
Authorized Official - Suffix:
Authorized Official - Credentials:STNA
Authorized Official - Phone:513-240-8757
Mailing Address - Street 1:PO BOX 141233
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45250-1233
Mailing Address - Country:US
Mailing Address - Phone:513-297-6575
Mailing Address - Fax:509-756-8484
Practice Address - Street 1:3047 GLENWAY AVE
Practice Address - Street 2:6908 GOLW WAY DRIVE
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45204-1646
Practice Address - Country:US
Practice Address - Phone:513-297-6575
Practice Address - Fax:509-756-8484
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WESTSIDE RESIDENTIAL INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-09-03
Last Update Date:2007-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health