1851873756 NPI number — LAKESIDE AESTHETICS - LLC

Table of content: (NPI 1851873756)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1851873756 NPI number — LAKESIDE AESTHETICS - LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LAKESIDE AESTHETICS - LLC
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 MEDICINE AND AESTHETICS LLC
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:
1851873756
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/06/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 333
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAGLE
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83860-0333
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-290-3302
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1005 HIGHWAY 2
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SANDPOINT
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83864-1702
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-290-3302
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/06/2018

Additional Information

Authorized Official

Authorized Official Last Name:
FUHRMAN
Authorized Official First Name:
KELLY
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER/NP
Authorized Official Telephone Number:
208-290-3302

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363L00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LF0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LP2300X , with the licence number: NP1029A , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: NP1029A . This is a "IDAHO STATE LICENSE NUMBER" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".




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