=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164446845
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PARKSIDE FACILITY OPERATIONS, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/27/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1430 OAK HARBOR RD
-----------------------------------------------------
City | FREMONT
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43420-1000
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 419-334-4914
-----------------------------------------------------
Fax | 419-332-0121
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 800 CONCOURSE PKWY S SUITE 200
-----------------------------------------------------
City | MAITLAND
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32751-6148
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-571-1550
-----------------------------------------------------
Fax | 407-571-1599
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIEF EXECUTIVE OFFICER
-----------------------------------------------------
Name | JOSEPH CONTE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 407-571-1550
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 310400000X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------