Provider Demographics
NPI:1215323118
Name:EASTSIDE ACTIVE LIVING LLC
Entity type:Organization
Organization Name:EASTSIDE ACTIVE LIVING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:MOSES
Authorized Official - Middle Name:
Authorized Official - Last Name:SYHEAD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:954-362-3487
Mailing Address - Street 1:1600 TAFT ST
Mailing Address - Street 2:
Mailing Address - City:HOLLYWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:33020-3272
Mailing Address - Country:US
Mailing Address - Phone:954-923-5057
Mailing Address - Fax:954-927-7794
Practice Address - Street 1:1600 TAFT ST
Practice Address - Street 2:
Practice Address - City:HOLLYWOOD
Practice Address - State:FL
Practice Address - Zip Code:33020-3272
Practice Address - Country:US
Practice Address - Phone:954-923-5057
Practice Address - Fax:954-927-7794
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-08
Last Update Date:2016-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL120233104A0625X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3104A0625XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Mental Illness