Provider Demographics
NPI:1417616202
Name:SOUTHSIDE DIABETES
Entity Type:Organization
Organization Name:SOUTHSIDE DIABETES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:DANA
Authorized Official - Middle Name:
Authorized Official - Last Name:STALLINGS
Authorized Official - Suffix:
Authorized Official - Credentials:DNP, APRN, FNP-C
Authorized Official - Phone:757-659-9903
Mailing Address - Street 1:1337 ARMORY DRIVE
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:VA
Mailing Address - Zip Code:23851-2419
Mailing Address - Country:US
Mailing Address - Phone:757-659-9903
Mailing Address - Fax:833-471-5922
Practice Address - Street 1:1337 ARMORY DRIVE
Practice Address - Street 2:
Practice Address - City:FRANKLIN
Practice Address - State:VA
Practice Address - Zip Code:23851-2419
Practice Address - Country:US
Practice Address - Phone:757-659-9903
Practice Address - Fax:833-471-5922
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-12-09
Last Update Date:2023-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
No261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical SpecialtyGroup - Single Specialty