Provider Demographics
NPI:1043200355
Name:LAKESIDE MEDICAL CENTER, INC.
Entity Type:Organization
Organization Name:LAKESIDE MEDICAL CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:MCMAHON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:320-629-2542
Mailing Address - Street 1:129 6TH AVE SE
Mailing Address - Street 2:
Mailing Address - City:PINE CITY
Mailing Address - State:MN
Mailing Address - Zip Code:55063-1913
Mailing Address - Country:US
Mailing Address - Phone:320-629-2542
Mailing Address - Fax:320-629-1093
Practice Address - Street 1:129 6TH AVE SE
Practice Address - Street 2:
Practice Address - City:PINE CITY
Practice Address - State:MN
Practice Address - Zip Code:55063-1913
Practice Address - Country:US
Practice Address - Phone:320-629-2542
Practice Address - Fax:320-629-1093
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-27
Last Update Date:2013-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN7111815OtherMEDICA
MN177550200Medicaid
MN0694ELAOtherBC/BS
MN0694ELAOtherBC/BS