Provider Demographics
NPI:1205249927
Name:EASTSIDE MANOR INC. DBA SOUTHERN OAKS
Entity type:Organization
Organization Name:EASTSIDE MANOR INC. DBA SOUTHERN OAKS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:GAIL
Authorized Official - Middle Name:ROBERTA
Authorized Official - Last Name:BOUDREAU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:864-288-3271
Mailing Address - Street 1:120 ROPER MOUNTAIN ROAD EXT
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29615-4823
Mailing Address - Country:US
Mailing Address - Phone:864-288-3271
Mailing Address - Fax:864-365-0697
Practice Address - Street 1:120 ROPER MOUNTAIN ROAD EXT
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29615-4823
Practice Address - Country:US
Practice Address - Phone:864-288-3271
Practice Address - Fax:864-365-0697
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-10
Last Update Date:2014-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCCRC0611310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility