Provider Demographics
NPI:1679604862
Name:WESTSIDE RESIDENTAIL
Entity type:Organization
Organization Name:WESTSIDE RESIDENTAIL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO PRESIDENT
Authorized Official - Prefix:MISS
Authorized Official - First Name:SHAWNTAY
Authorized Official - Middle Name:CORISHA
Authorized Official - Last Name:OLIVER
Authorized Official - Suffix:
Authorized Official - Credentials:CEO,EMT,STNA,CNA
Authorized Official - Phone:513-766-8484
Mailing Address - Street 1:6908 GOLFWAY DR
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45239-5631
Mailing Address - Country:US
Mailing Address - Phone:513-766-8484
Mailing Address - Fax:513-681-5832
Practice Address - Street 1:3047 GLENWAY AVE APT 3
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45204-1646
Practice Address - Country:US
Practice Address - Phone:513-766-8484
Practice Address - Fax:513-681-5832
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health