Provider Demographics
NPI:1467902502
Name:WHITESIDE MANOR, PALM FACILITY
Entity Type:Organization
Organization Name:WHITESIDE MANOR, PALM FACILITY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATIVE MANAGER
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:951-847-8010
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:951-788-9515
Mailing Address - Fax:
Practice Address - Street 1:4750 PALM AVE
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92501-4012
Practice Address - Country:US
Practice Address - Phone:951-788-9515
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WHITESIDE MANOR
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-10-13
Last Update Date:2016-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility