Provider Demographics
NPI:1740802354
Name:SOUTHSIDE PERSONAL CARE HOME LLC
Entity Type:Organization
Organization Name:SOUTHSIDE PERSONAL CARE HOME LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:ABDIRASHID
Authorized Official - Middle Name:AHMED
Authorized Official - Last Name:KANYARE
Authorized Official - Suffix:
Authorized Official - Credentials:ADMIN
Authorized Official - Phone:502-533-1492
Mailing Address - Street 1:5330 S 3RD ST STE 200
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40214-2689
Mailing Address - Country:US
Mailing Address - Phone:502-533-1492
Mailing Address - Fax:502-212-9292
Practice Address - Street 1:5330 S 3RD ST STE 200
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40214-2689
Practice Address - Country:US
Practice Address - Phone:502-533-1492
Practice Address - Fax:502-212-9292
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-05-18
Last Update Date:2020-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes374U00000XNursing Service Related ProvidersHome Health AideGroup - Single Specialty