Provider Demographics
NPI:1366677361
Name:LAKEVIEW
Entity Type:Organization
Organization Name:LAKEVIEW
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:
Authorized Official - Last Name:HARRISON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-734-0266
Mailing Address - Street 1:PO BOX 1017
Mailing Address - Street 2:
Mailing Address - City:GOLDSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27533-1017
Mailing Address - Country:US
Mailing Address - Phone:919-734-0266
Mailing Address - Fax:919-734-9926
Practice Address - Street 1:103 LAKEVIEW DR
Practice Address - Street 2:
Practice Address - City:GOLDSBORO
Practice Address - State:NC
Practice Address - Zip Code:27530-1125
Practice Address - Country:US
Practice Address - Phone:919-734-0266
Practice Address - Fax:919-734-9926
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:RENU LIFE, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-05-19
Last Update Date:2009-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL-096-092320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7803548Medicaid