Provider Demographics
NPI:1033505011
Name:LAKESIDE BILLING SERVICES
Entity Type:Organization
Organization Name:LAKESIDE BILLING SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHANNA
Authorized Official - Middle Name:
Authorized Official - Last Name:SALTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-755-4694
Mailing Address - Street 1:6280 W 9600 N
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND
Mailing Address - State:UT
Mailing Address - Zip Code:84003-9234
Mailing Address - Country:US
Mailing Address - Phone:801-703-7289
Mailing Address - Fax:801-855-7207
Practice Address - Street 1:6280 W 9600 N
Practice Address - Street 2:
Practice Address - City:HIGHLAND
Practice Address - State:UT
Practice Address - Zip Code:84003-9234
Practice Address - Country:US
Practice Address - Phone:801-703-7289
Practice Address - Fax:801-855-7207
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ILLUME CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-04-07
Last Update Date:2015-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT101YM0800X, 101YP2500X, 103TA0400X, 324500000X
207QA0401X, 323P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)Group - Multi-Specialty
No207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction MedicineGroup - Multi-Specialty
No323P00000XResidential Treatment FacilitiesPsychiatric Residential Treatment Facility
No324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation FacilityGroup - Multi-Specialty