Provider Demographics
NPI:1326494105
Name:LAKESIDE HOME CARE SERVICES
Entity Type:Organization
Organization Name:LAKESIDE HOME CARE SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:LAKINA
Authorized Official - Middle Name:
Authorized Official - Last Name:LAKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-321-0440
Mailing Address - Street 1:4222 W GREEN ST
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33607-4102
Mailing Address - Country:US
Mailing Address - Phone:813-321-0440
Mailing Address - Fax:813-280-9151
Practice Address - Street 1:4222 W GREEN ST
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33607-4102
Practice Address - Country:US
Practice Address - Phone:813-321-0440
Practice Address - Fax:813-280-9151
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-10
Last Update Date:2016-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL234419253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL234419OtherHOMEMAKER & COMPAINION SERVICES