Provider Demographics
NPI:1033554837
Name:EST 400 OF WACO LLC
Entity Type:Organization
Organization Name:EST 400 OF WACO LLC
Other - Org Name:LAKE SHORE CENTER FOR BEHAVIORAL HEALTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BUSINESS/OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:RUBY
Authorized Official - Middle Name:C
Authorized Official - Last Name:SANTIBANEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:254-776-0400
Mailing Address - Street 1:4555 LAKE SHORE DR
Mailing Address - Street 2:
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76710-1814
Mailing Address - Country:US
Mailing Address - Phone:254-776-0400
Mailing Address - Fax:254-776-0637
Practice Address - Street 1:4555 LAKE SHORE DR
Practice Address - Street 2:
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76710-1814
Practice Address - Country:US
Practice Address - Phone:254-776-0400
Practice Address - Fax:254-776-0637
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-07
Last Update Date:2013-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)