Provider Demographics
NPI:1922876895
Name:WATERSIDE HEALTHCARE SERVICES INC
Entity Type:Organization
Organization Name:WATERSIDE HEALTHCARE SERVICES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NP
Authorized Official - Prefix:
Authorized Official - First Name:TAIWO
Authorized Official - Middle Name:ODUKOYA
Authorized Official - Last Name:ODUTOLA
Authorized Official - Suffix:
Authorized Official - Credentials:OWNER
Authorized Official - Phone:310-927-2119
Mailing Address - Street 1:21880 ORRICK AVE
Mailing Address - Street 2:
Mailing Address - City:CARSON
Mailing Address - State:CA
Mailing Address - Zip Code:90745-3052
Mailing Address - Country:US
Mailing Address - Phone:310-927-2119
Mailing Address - Fax:
Practice Address - Street 1:21880 ORRICK AVE
Practice Address - Street 2:
Practice Address - City:CARSON
Practice Address - State:CA
Practice Address - Zip Code:90745-3052
Practice Address - Country:US
Practice Address - Phone:310-927-2119
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-12-19
Last Update Date:2023-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty