Provider Demographics
NPI:1124154414
Name:DOCKSIDE SERVICES INC.
Entity type:Organization
Organization Name:DOCKSIDE SERVICES INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:ELENA
Authorized Official - Middle Name:
Authorized Official - Last Name:DWYRE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:219-736-4817
Mailing Address - Street 1:10304 SPOTSYLVANIA AVE
Mailing Address - Street 2:STE 300
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:22408-8602
Mailing Address - Country:US
Mailing Address - Phone:540-710-6085
Mailing Address - Fax:540-710-6447
Practice Address - Street 1:8695 CONNECTICUT ST
Practice Address - Street 2:STE B
Practice Address - City:MERRILLVILLE BRA
Practice Address - State:IN
Practice Address - Zip Code:46410-6387
Practice Address - Country:US
Practice Address - Phone:219-736-4817
Practice Address - Fax:219-736-4827
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN370346298 53782251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management