Southside Manor Inc.

Primary specialty

Intellectual and/or Developmental Disabilities Community Based Residential Treatment FacilityTaxonomy code 320900000X

License

191502984 Issued in CA

Legal business name

SOUTHSIDE MANOR INC.

Practice address

820 E Grand Ave
Pomona, CA 91766-3662

Phone

(909) 623-7305

Fax

(909) 623-7898

NPI assigned

Jul 23, 2009

Organization subpart

No

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

Authorized official

Name

James Pardue

Title

President

Phone

(909) 623-7305

Specialties & licenses 1

Addresses

Other identifiers 1

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

{
    "created_epoch": "1248307200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1251244800000",
    "number": "1528298502",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "820 E GRAND AVE",
            "city": "POMONA",
            "state": "CA",
            "postal_code": "917663662",
            "telephone_number": "909-623-7305",
            "fax_number": "909-623-7898"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "820 E GRAND AVE",
            "city": "POMONA",
            "state": "CA",
            "postal_code": "917663662",
            "telephone_number": "909-623-7305",
            "fax_number": "909-623-7898"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SOUTHSIDE MANOR INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2009-07-23",
        "last_updated": "2009-08-26",
        "status": "A",
        "authorized_official_last_name": "PARDUE",
        "authorized_official_first_name": "JAMES",
        "authorized_official_title_or_position": "PRESIDENT",
        "authorized_official_telephone_number": "909-623-7305"
    },
    "taxonomies": [
        {
            "code": "320900000X",
            "taxonomy_group": "",
            "desc": "Community Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities",
            "state": "CA",
            "license": "191502984",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "DOMICILIARY CARE FACITITIY",
            "identifier": "320900000X",
            "state": "CA"
        }
    ],
    "endpoints": [],
    "other_names": []
}

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• Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility in Pomona, CA
• Providers in Pomona, CA by specialty
• Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility in California

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 26, 2009; 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.