1093185928 NPI number — LAKESIDE MEDICAL GROUP

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093185928 NPI number — LAKESIDE MEDICAL GROUP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LAKESIDE MEDICAL GROUP
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:
1093185928
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/23/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 108
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BOWLING GREEN
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
43402-0108
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
188-844-9779
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
HIDALGO 244
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHAPALA
Provider Business Practice Location Address State Name:
MEXICO
Provider Business Practice Location Address Postal Code:
45920
Provider Business Practice Location Address Country Code:
MX
Provider Business Practice Location Address Telephone Number:
888-449-7799
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/05/2015

Additional Information

Authorized Official

Authorized Official Last Name:
ZAZUETA
Authorized Official First Name:
ANA
Authorized Official Middle Name:
RENTERIA
Authorized Official Title or Position:
OPERATIONS MANAGER-OWNER
Authorized Official Telephone Number:
888-449-7799

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  DGP8902484 , registered in the state of ZZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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