Basic Information
| Provider Information | |||||||||
| NPI: | 1124154414 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DOCKSIDE SERVICES INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10304 SPOTSYLVANIA AVE | ||||||||
| Address2: | STE 300 | ||||||||
| City: | FREDERICKSBURG | ||||||||
| State: | VA | ||||||||
| PostalCode: | 224088602 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5407106085 | ||||||||
| FaxNumber: | 5407106447 | ||||||||
| Practice Location | |||||||||
| Address1: | 8695 CONNECTICUT ST | ||||||||
| Address2: | STE B | ||||||||
| City: | MERRILLVILLE BRA | ||||||||
| State: | IN | ||||||||
| PostalCode: | 464106387 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2197364817 | ||||||||
| FaxNumber: | 2197364827 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/23/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | DWYRE | ||||||||
| AuthorizedOfficialFirstName: | ELENA | ||||||||
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| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2197364817 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251B00000X | 370346298 53782 | IN | Y | Agencies | Case Management |
No ID Information.