Provider Demographics
NPI:1588967723
Name:WESTSIDE GROUP HOME, INC.
Entity type:Organization
Organization Name:WESTSIDE GROUP HOME, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSD
Authorized Official - Prefix:MRS
Authorized Official - First Name:ILIANA
Authorized Official - Middle Name:R
Authorized Official - Last Name:STOKES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:941-794-5759
Mailing Address - Street 1:6304 1ST AVE W
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34209-2331
Mailing Address - Country:US
Mailing Address - Phone:941-794-5759
Mailing Address - Fax:941-794-5759
Practice Address - Street 1:2602 43RD ST W
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34209-6212
Practice Address - Country:US
Practice Address - Phone:941-795-1084
Practice Address - Fax:941-792-0385
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-09
Last Update Date:2010-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL3209000000X320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities