Healthcare Provider Details

I. General information

NPI: 1992843577
Provider Name (Legal Business Name): WATERSIDE HEALTHCARE INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/03/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

703 ELIZABETH ST
TABOR CITY NC
28463-2603
US

IV. Provider business mailing address

PO BOX 1559
SHALLOTTE NC
28459-1559
US

V. Phone/Fax

Practice location:
  • Phone: 910-653-6400
  • Fax:
Mailing address:
  • Phone: 910-754-6621
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License NumberHAL-024-008
License Number StateNC

VIII. Authorized Official

Name: MR. DAVID B GOLDSTON III
Title or Position: PRESIDENT
Credential:
Phone: 910-754-6621