Provider Demographics
NPI:1275903833
Name:LAKESIDE YOUTH N KIDS PEDIATRICS
Entity Type:Organization
Organization Name:LAKESIDE YOUTH N KIDS PEDIATRICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LANCE
Authorized Official - Middle Name:JESSE
Authorized Official - Last Name:LAZATIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:916-300-7534
Mailing Address - Street 1:6055 W 46TH AVE
Mailing Address - Street 2:
Mailing Address - City:WHEAT RIDGE
Mailing Address - State:CO
Mailing Address - Zip Code:80033-1811
Mailing Address - Country:US
Mailing Address - Phone:916-300-7534
Mailing Address - Fax:
Practice Address - Street 1:6055 W 46TH AVE
Practice Address - Street 2:
Practice Address - City:WHEAT RIDGE
Practice Address - State:CO
Practice Address - Zip Code:80033-1811
Practice Address - Country:US
Practice Address - Phone:916-300-7534
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-25
Last Update Date:2015-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO50291261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO63008564Medicaid