1336492495 NPI number — LAKESIDE HEALTH CLINIC, P.C.

Table of content: (NPI 1336492495)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336492495 NPI number — LAKESIDE HEALTH CLINIC, P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LAKESIDE HEALTH CLINIC, P.C.
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:
1336492495
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/16/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1269
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PARIS
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
38242-1269
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
731-924-2000
Provider Business Mailing Address Fax Number:
731-653-0053

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
813 E WOOD ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PARIS
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
38242-4223
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
731-924-2000
Provider Business Practice Location Address Fax Number:
731-653-0053
Provider Enumeration Date:
10/25/2012

Additional Information

Authorized Official

Authorized Official Last Name:
HUBBARD
Authorized Official First Name:
LISA
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER/PA-C
Authorized Official Telephone Number:
731-924-2000

Provider Taxonomy Codes

  • Taxonomy code: 208D00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 261QR1300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 1530820 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".




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