MEDICARE: SOUTHSIDE ADULT DAYCARE CENTER, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QA0600X	Adult Day Care Clinic/Center

General Provider Information

NPI Number	:	1861709594
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTHSIDE ADULT DAYCARE CENTER, INC.

Provider Business Mailing Address
First Line	:	1401 CLINTON AVE
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76164-9143
Country	:	US
Telephone Number	:	817-740-1611
Fax Number	:	817-740-1667

Provider Business Practice Location Address
First Line	:	1700 SOUTH FWY
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76104-5078
Country	:	US
Telephone Number	:	817-740-1611
Fax Number	:	817-740-1667

Authorized Official
Title or Position	:	OWNER
Name	:	MRS. VERONICA ALANIZ
Credential	:	LVN
Telephone Number	:	817-740-1611

Provider Enumeration Date	:	09/01/2010
Last Update Date	:	08/10/2011

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