Provider Demographics
NPI:1356796668
Name:WOODSIDE HEALTHCARE
Entity type:Organization
Organization Name:WOODSIDE HEALTHCARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:ISAIAH
Authorized Official - Middle Name:A
Authorized Official - Last Name:TEASLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:240-750-0045
Mailing Address - Street 1:1010 SOUTHERN NIGHT LN
Mailing Address - Street 2:
Mailing Address - City:GAITHERSBURG
Mailing Address - State:MD
Mailing Address - Zip Code:20879-3268
Mailing Address - Country:US
Mailing Address - Phone:240-750-0045
Mailing Address - Fax:
Practice Address - Street 1:4309 KENWOOD DR
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22193-5282
Practice Address - Country:US
Practice Address - Phone:240-750-0045
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-25
Last Update Date:2016-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA08041139320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities