Provider Demographics
NPI:1013382225
Name:LAKESIDE MANOR NURSING & REHABILITATION CENTER LLC
Entity Type:Organization
Organization Name:LAKESIDE MANOR NURSING & REHABILITATION CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:FAHIM
Authorized Official - Middle Name:
Authorized Official - Last Name:UDDIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-593-1990
Mailing Address - Street 1:30700 TELEGRAPH RD
Mailing Address - Street 2:SUITE 2504
Mailing Address - City:BINGHAM FARMS
Mailing Address - State:MI
Mailing Address - Zip Code:48025-4524
Mailing Address - Country:US
Mailing Address - Phone:248-593-1990
Mailing Address - Fax:248-593-9120
Practice Address - Street 1:13990 LAKESIDE CIR
Practice Address - Street 2:
Practice Address - City:STERLING HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48313-1318
Practice Address - Country:US
Practice Address - Phone:586-488-1400
Practice Address - Fax:844-276-4323
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-14
Last Update Date:2017-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
235719Medicare Oscar/Certification