1407512791 NPI number — LAKESIDE MEDICAL GROUP HOSPITAL

Table of content: (NPI 1407512791)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407512791 NPI number — LAKESIDE MEDICAL GROUP HOSPITAL

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LAKESIDE MEDICAL GROUP HOSPITAL
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:
1407512791
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/11/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
LAKESIDE MEDICAL GROUP HOSPITAL
Provider Second Line Business Mailing Address:
302 WASHINGTON ST #150-3509
Provider Business Mailing Address City Name:
SAN DIEGO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92103
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
LAKESIDE MEDICAL GROUP HOSPITAL
Provider Second Line Business Practice Location Address:
HIDALGO 148A
Provider Business Practice Location Address City Name:
CHAPALA
Provider Business Practice Location Address State Name:
JALISCO
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:
11/11/2021

Additional Information

Authorized Official

Authorized Official Last Name:
FISCHMAN
Authorized Official First Name:
IAN
Authorized Official Middle Name:
Authorized Official Title or Position:
MANAGER
Authorized Official Telephone Number:
650-417-1127

Provider Taxonomy Codes

  • Taxonomy code: 207P00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: COFEPRIS . This is a "STATE" identifier . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com