1134292501 NPI number — LAKESIDE RECOVERY CENTERS INC

Table of content: (NPI 1134292501)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134292501 NPI number — LAKESIDE RECOVERY CENTERS INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LAKESIDE RECOVERY CENTERS INC
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:
LAKESIDE MILAM RECOVERY CENTERS
Provider Other Organization Name Type Code:
3
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:
1134292501
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10322 NE132ND ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KIRKLAND
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98034
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
425-823-3116
Provider Business Mailing Address Fax Number:
425-823-3132

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12845 AMBAUM BLVD SW
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SEATTLE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98146
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
206-241-0890
Provider Business Practice Location Address Fax Number:
206-241-0769
Provider Enumeration Date:
11/15/2006

Additional Information

Authorized Official

Authorized Official Last Name:
KESTER
Authorized Official First Name:
CARLTON
Authorized Official Middle Name:
M
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
425-823-3116

Provider Taxonomy Codes

  • Taxonomy code: 3245S0500X , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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