Eastside Active Living LLC

Primary specialty

Assisted Living Facility (Mental Illness)Taxonomy code 3104A0625X

License

AL12023 Issued in FL

Legal business name

EASTSIDE ACTIVE LIVING LLC

Practice address

1600 Taft St
Hollywood, FL 33020-3272

Phone

(954) 923-5057

Fax

(954) 927-7794

NPI assigned

Apr 8, 2015

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Mr. Moses Syhead

Title

Manager

Phone

(954) 362-3487

Specialties & licenses 1

Addresses

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1428451200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1463961600000",
    "number": "1215323118",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1600 TAFT ST",
            "city": "HOLLYWOOD",
            "state": "FL",
            "postal_code": "330203272",
            "telephone_number": "954-923-5057",
            "fax_number": "954-927-7794"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1600 TAFT ST",
            "city": "HOLLYWOOD",
            "state": "FL",
            "postal_code": "330203272",
            "telephone_number": "954-923-5057",
            "fax_number": "954-927-7794"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "EASTSIDE ACTIVE LIVING LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2015-04-08",
        "last_updated": "2016-05-23",
        "status": "A",
        "authorized_official_last_name": "SYHEAD",
        "authorized_official_first_name": "MOSES",
        "authorized_official_title_or_position": "MANAGER",
        "authorized_official_telephone_number": "954-362-3487",
        "authorized_official_name_prefix": "Mr."
    },
    "taxonomies": [
        {
            "code": "3104A0625X",
            "taxonomy_group": "",
            "desc": "Assisted Living Facility, Assisted Living, Mental Illness",
            "state": "FL",
            "license": "AL12023",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

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• Mary E. Ebanks-Nunaihed, DPT
• McKenzie Lynn Ebel
• Bertrand Fabien Ebner, M.D.

• Assisted Living Facility (Mental Illness) in Hollywood, FL
• Providers in Hollywood, FL by specialty
• Assisted Living Facility (Mental Illness) in Florida

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 23, 2016; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.