Provider Demographics
NPI:1376107904
Name:LAKE PLEASANT HEALTHCARE, INC.
Entity Type:Organization
Organization Name:LAKE PLEASANT HEALTHCARE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:TREASURER
Authorized Official - Prefix:
Authorized Official - First Name:SOON
Authorized Official - Middle Name:
Authorized Official - Last Name:BURNAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:949-540-1249
Mailing Address - Street 1:20625 N LAKE PLEASANT RD
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85382-9704
Mailing Address - Country:US
Mailing Address - Phone:623-566-0642
Mailing Address - Fax:623-476-3664
Practice Address - Street 1:20625 N LAKE PLEASANT RD
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85382-9704
Practice Address - Country:US
Practice Address - Phone:623-566-0642
Practice Address - Fax:623-476-3664
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-04-29
Last Update Date:2019-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0401XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Comprehensive Outpatient Rehabilitation Facility (CORF)
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZOTC9114OtherAZ DEPARTMENT OF HEALTH SERVICES