Provider Demographics
NPI:1871006734
Name:PARKSIDE ASSISTED LIVING AND MEMORY COTTAGE
Entity Type:Organization
Organization Name:PARKSIDE ASSISTED LIVING AND MEMORY COTTAGE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SAKINA
Authorized Official - Middle Name:
Authorized Official - Last Name:KHALIDI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:941-629-2111
Mailing Address - Street 1:PO BOX 496420
Mailing Address - Street 2:
Mailing Address - City:PORT CHARLOTTE
Mailing Address - State:FL
Mailing Address - Zip Code:33949-6420
Mailing Address - Country:US
Mailing Address - Phone:941-629-2111
Mailing Address - Fax:941-627-5377
Practice Address - Street 1:2595 HARBOR BLVD
Practice Address - Street 2:
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33952-6724
Practice Address - Country:US
Practice Address - Phone:941-766-7444
Practice Address - Fax:941-979-5884
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-14
Last Update Date:2017-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL13075310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility