Healthcare Provider Details

I. General information

NPI: 1225012636
Provider Name (Legal Business Name): WESTSIDE TERRACE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/30/2005
Last Update Date: 03/29/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 N WOODBURN DR
DOTHAN AL
36303-1995
US

IV. Provider business mailing address

501 N WOODBURN DR
DOTHAN AL
36303-1995
US

V. Phone/Fax

Practice location:
  • Phone: 334-794-1000
  • Fax: 334-794-5287
Mailing address:
  • Phone: 334-794-1000
  • Fax: 334-794-5287

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number10540
License Number StateAL

VIII. Authorized Official

Name: MRS. RHONDA RENEE TATE
Title or Position: COMPTROLLER
Credential:
Phone: 334-794-1000