=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225789688
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WOODSIDE PLACE ASSISTED LIVING LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/17/2022
-----------------------------------------------------
Last Update Date | 01/17/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2705 WOODSIDE DR
-----------------------------------------------------
City | ARLINGTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76016-1818
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 682-551-9059
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5867 LORENZO DR
-----------------------------------------------------
City | GRAND PRAIRIE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75052-8765
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 682-551-9059
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/MANAGER
-----------------------------------------------------
Name | MRS. OLUWATOYIN B AKINYODE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 682-551-9059
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 310400000X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------