Provider Demographics
NPI:1265121800
Name:PARKSIDE ADULT FAMILY HOME LLC
Entity type:Organization
Organization Name:PARKSIDE ADULT FAMILY HOME LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:JUDITH
Authorized Official - Middle Name:K
Authorized Official - Last Name:NYARIBO
Authorized Official - Suffix:
Authorized Official - Credentials:BSN,RN
Authorized Official - Phone:168-241-0388
Mailing Address - Street 1:1702 S HIGHLANDS BLVD # A
Mailing Address - Street 2:
Mailing Address - City:WEST RICHLAND
Mailing Address - State:WA
Mailing Address - Zip Code:99353-6778
Mailing Address - Country:US
Mailing Address - Phone:168-241-0388
Mailing Address - Fax:
Practice Address - Street 1:1702 S HIGHLANDS BLVD # A
Practice Address - Street 2:
Practice Address - City:WEST RICHLAND
Practice Address - State:WA
Practice Address - Zip Code:99353-6778
Practice Address - Country:US
Practice Address - Phone:168-241-0388
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-05-01
Last Update Date:2023-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility