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General NPI Number Information
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NPI Number | 1578697660
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Entity Type | Organization
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Legal Business Name | EASTSIDE VENTURES INC.
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Dates
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Enumeration Date | 03/14/2007
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Last Update Date | 02/03/2011
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Provider Practice Location Address
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Address Line | 150 GILBREATH DR SUITE 201
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City | ONEONTA
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State | AL
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Zip | 35121-2827
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Country | US
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Telephone | 205-274-3055
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Fax |
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Provider Business Mailing Address
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Address Line | 150 GILBREATH DR SUITE 201
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City | ONEONTA
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State | AL
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Zip | 35121-2827
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Country | US
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Telephone | 205-274-3055
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Fax |
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Authorized Official
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Title or Position | CHIEF ACCOUNTING OFFICER
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Name | MRS. VICKI H PARKS
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Credential | CPA
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Telephone | 205-838-3718
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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