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General NPI Number Information
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NPI Number | 1205249927
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Entity Type | Organization
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Legal Business Name | EASTSIDE MANOR INC. DBA SOUTHERN OAKS
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Dates
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Enumeration Date | 06/10/2014
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Last Update Date | 06/10/2014
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Provider Practice Location Address
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Address Line | 120 ROPER MOUNTAIN ROAD EXT
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City | GREENVILLE
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State | SC
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Zip | 29615-4823
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Country | US
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Telephone | 864-288-3271
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Fax | 864-365-0697
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Provider Business Mailing Address
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Address Line | 120 ROPER MOUNTAIN ROAD EXT
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City | GREENVILLE
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State | SC
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Zip | 29615-4823
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Country | US
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Telephone | 864-288-3271
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Fax | 864-365-0697
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | MRS. GAIL ROBERTA BOUDREAU
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Credential |
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Telephone | 864-288-3271
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 310400000X
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Taxonomy Name | Assisted Living Facility
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License Number | CRC0611
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License Number State | SC
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