Provider Demographics
NPI:1306018361
Name:LAKESIDE GUEST HOME, INC.
Entity Type:Organization
Organization Name:LAKESIDE GUEST HOME, INC.
Other - Org Name:ROLLING HILLS RESIDENTIAL CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:LICENSEE/ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:DIANA
Authorized Official - Middle Name:KAY
Authorized Official - Last Name:BISHOP
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:805-610-7861
Mailing Address - Street 1:9220 MT VIEW DR
Mailing Address - Street 2:
Mailing Address - City:ATASCADERO
Mailing Address - State:CA
Mailing Address - Zip Code:93422-5016
Mailing Address - Country:US
Mailing Address - Phone:805-466-0250
Mailing Address - Fax:
Practice Address - Street 1:9220 MT VIEW DR
Practice Address - Street 2:
Practice Address - City:ATASCADERO
Practice Address - State:CA
Practice Address - Zip Code:93422-5016
Practice Address - Country:US
Practice Address - Phone:805-466-0250
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-31
Last Update Date:2008-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA3104A0630X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3104A0630XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Behavioral Disturbances