Provider Demographics
NPI:1699929612
Name:SOUTHSIDE RES. CARE
Entity type:Organization
Organization Name:SOUTHSIDE RES. CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:ROY
Authorized Official - Middle Name:L
Authorized Official - Last Name:BOWERS
Authorized Official - Suffix:SR
Authorized Official - Credentials:
Authorized Official - Phone:803-364-0022
Mailing Address - Street 1:425 S. WHEELER AVE
Mailing Address - Street 2:
Mailing Address - City:PROSPERITY
Mailing Address - State:SC
Mailing Address - Zip Code:29127
Mailing Address - Country:US
Mailing Address - Phone:803-364-0022
Mailing Address - Fax:803-364-8250
Practice Address - Street 1:425 S. WHEELER AVE
Practice Address - Street 2:
Practice Address - City:PROS
Practice Address - State:SC
Practice Address - Zip Code:29127
Practice Address - Country:US
Practice Address - Phone:803-364-0022
Practice Address - Fax:803-364-8250
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-05
Last Update Date:2008-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness