Provider Demographics
NPI:1669899910
Name:PARKSIDE ESTATES
Entity type:Organization
Organization Name:PARKSIDE ESTATES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINSTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:RICHARDS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:734-692-0877
Mailing Address - Street 1:2211 PARKSIDE ST
Mailing Address - Street 2:
Mailing Address - City:TRENTON
Mailing Address - State:MI
Mailing Address - Zip Code:48183-2512
Mailing Address - Country:US
Mailing Address - Phone:734-692-0877
Mailing Address - Fax:
Practice Address - Street 1:28860 COLEMAN DR
Practice Address - Street 2:
Practice Address - City:GROSSE ILE
Practice Address - State:MI
Practice Address - Zip Code:48138-2053
Practice Address - Country:US
Practice Address - Phone:734-692-0877
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-25
Last Update Date:2014-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIAS820313332302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI=========Medicaid