Provider Demographics
NPI:1609900406
Name:EASTSIDE VENTURES, INC.
Entity Type:Organization
Organization Name:EASTSIDE VENTURES, INC.
Other - Org Name:CLEVELAND FAMILY HEALTHCARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF ACCOUNTING OFFICER
Authorized Official - Prefix:MRS
Authorized Official - First Name:VICKI
Authorized Official - Middle Name:H
Authorized Official - Last Name:PARKS
Authorized Official - Suffix:
Authorized Official - Credentials:CPA
Authorized Official - Phone:205-838-3718
Mailing Address - Street 1:PO BOX 232
Mailing Address - Street 2:
Mailing Address - City:ONEONTA
Mailing Address - State:AL
Mailing Address - Zip Code:35121-0004
Mailing Address - Country:US
Mailing Address - Phone:205-625-3667
Mailing Address - Fax:
Practice Address - Street 1:6945 COUNTY HIGHWAY 1
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:AL
Practice Address - Zip Code:35049
Practice Address - Country:US
Practice Address - Phone:205-625-3667
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EASTSIDE VENTURES, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-03-15
Last Update Date:2011-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
E892OtherMEDICARE PT B
AL529703160Medicaid