1609055276 NPI number — LAKESIDE NEUROLOGY LLC

Table of content: (NPI 1609055276)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609055276 NPI number — LAKESIDE NEUROLOGY LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LAKESIDE NEUROLOGY 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:
Provider Other Organization Name Type Code:
6
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:
1609055276
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/30/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1440
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAKE HAVASU CITY
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
86405-1440
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
928-680-8282
Provider Business Mailing Address Fax Number:
928-680-8288

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2180 MCCULLOCH BLVD N
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAKE HAVASU CITY
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
86403-6879
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
928-680-8282
Provider Business Practice Location Address Fax Number:
928-680-8288
Provider Enumeration Date:
10/30/2007

Additional Information

Authorized Official

Authorized Official Last Name:
WIN
Authorized Official First Name:
TIN
Authorized Official Middle Name:
T
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
928-680-8282

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  28212 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1659357929 . This is a "GROUP NPI NUMBER" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com