Provider Demographics
NPI:1124385000
Name:RELIANT LAKESIDE HOLDINGS LLC
Entity Type:Organization
Organization Name:RELIANT LAKESIDE HOLDINGS LLC
Other - Org Name:LAKESIDE HEALTH AND REHABILITATION CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:MARC
Authorized Official - Middle Name:
Authorized Official - Last Name:MYZAL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:215-558-3700
Mailing Address - Street 1:3601 ISLAND AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19153-3228
Mailing Address - Country:US
Mailing Address - Phone:215-558-3700
Mailing Address - Fax:215-558-3701
Practice Address - Street 1:RR 4 BOX 357
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:PA
Practice Address - Zip Code:18612-9236
Practice Address - Country:US
Practice Address - Phone:570-639-1885
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-18
Last Update Date:2012-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility