1043697832 NPI number — LAKESIDE CENTER

Table of content: (NPI 1043697832)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043697832 NPI number — LAKESIDE CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LAKESIDE CENTER
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1043697832
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/30/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 13296
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHESAPEAKE
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
23325-0296
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
757-714-1838
Provider Business Mailing Address Fax Number:
757-321-6269

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6515 GEORGE WASHINGTON MEM HWY
Provider Second Line Business Practice Location Address:
# 101
Provider Business Practice Location Address City Name:
YORKTOWN
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23692-2182
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
757-714-1838
Provider Business Practice Location Address Fax Number:
757-321-6269
Provider Enumeration Date:
04/30/2015

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
LEITCH-ALFORD
Authorized Official First Name:
LINDA
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
757-874-0468

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)