=====================================================
General NPI Number Information
=====================================================
NPI Number | 1992843577
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WATERSIDE HEALTHCARE INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/03/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 703 ELIZABETH ST
-----------------------------------------------------
City | TABOR CITY
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28463-2603
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-653-6400
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1559
-----------------------------------------------------
City | SHALLOTTE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28459-1559
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-754-6621
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MR. DAVID B GOLDSTON III
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 910-754-6621
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 311ZA0620X
-----------------------------------------------------
Taxonomy Name | Adult Care Home Facility
-----------------------------------------------------
License Number | HAL-024-008
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------