Provider Demographics
NPI:1295211316
Name:SOUTHSIDE SERVICES, LLC
Entity type:Organization
Organization Name:SOUTHSIDE SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:ANNIE
Authorized Official - Middle Name:J
Authorized Official - Last Name:SCOTT
Authorized Official - Suffix:
Authorized Official - Credentials:MA
Authorized Official - Phone:757-309-1405
Mailing Address - Street 1:1844 BURWILLOW DR
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23464-8945
Mailing Address - Country:US
Mailing Address - Phone:757-309-1405
Mailing Address - Fax:
Practice Address - Street 1:1545 CROSSWAYS BLVD STE 250
Practice Address - Street 2:
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23320-0218
Practice Address - Country:US
Practice Address - Phone:757-309-1405
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-11
Last Update Date:2018-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2356251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health