Provider Demographics
NPI:1467590042
Name:WATERSIDE HEALTHCARE INC.
Entity Type:Organization
Organization Name:WATERSIDE HEALTHCARE INC.
Other - Org Name:SHALLOTTE ASSISTED LIVING
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:B
Authorized Official - Last Name:GOLDSTON
Authorized Official - Suffix:III
Authorized Official - Credentials:
Authorized Official - Phone:910-754-6621
Mailing Address - Street 1:PO BOX 1559
Mailing Address - Street 2:
Mailing Address - City:SHALLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28459-1559
Mailing Address - Country:US
Mailing Address - Phone:910-754-6621
Mailing Address - Fax:
Practice Address - Street 1:520 MULBERRY ST
Practice Address - Street 2:
Practice Address - City:SHALLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28470-4586
Practice Address - Country:US
Practice Address - Phone:910-754-6621
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCHAL-010-004311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7805372Medicaid