Provider Demographics
NPI:1710100979
Name:WESTSIDE SUPPORT SERVICES LLC
Entity Type:Organization
Organization Name:WESTSIDE SUPPORT SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER OPERATOR
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:J
Authorized Official - Last Name:CONRAD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:740-689-0963
Mailing Address - Street 1:639 BRUMFIELD RD
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:OH
Mailing Address - Zip Code:43130-2801
Mailing Address - Country:US
Mailing Address - Phone:740-689-0963
Mailing Address - Fax:740-689-0971
Practice Address - Street 1:639 BRUMFIELD RD
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:OH
Practice Address - Zip Code:43130-2801
Practice Address - Country:US
Practice Address - Phone:740-689-0963
Practice Address - Fax:740-689-0971
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH251C00000X251C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH105281184999Medicaid
OH106605966699Medicaid
OH103426545299Medicaid
OH107324031799Medicaid
OH231011069301Medicaid
OH413004901001Medicaid
OH231007893201Medicaid
OH053024742801Medicaid