Healthcare Provider Details

I. General information

NPI: 1124154414
Provider Name (Legal Business Name): DOCKSIDE SERVICES INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/23/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8695 CONNECTICUT ST STE B
MERRILLVILLE BRA IN
46410-6387
US

IV. Provider business mailing address

10304 SPOTSYLVANIA AVE STE 300
FREDERICKSBURG VA
22408-8602
US

V. Phone/Fax

Practice location:
  • Phone: 219-736-4817
  • Fax: 219-736-4827
Mailing address:
  • Phone: 540-710-6085
  • Fax: 540-710-6447

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number370346298 53782
License Number StateIN

VIII. Authorized Official

Name: MS. ELENA DWYRE
Title or Position: VICE PRESIDENT
Credential:
Phone: 219-736-4817