Provider Demographics
NPI:1407147234
Name:LAKESIDE MEDICAL WELLNESS CLINIC
Entity Type:Organization
Organization Name:LAKESIDE MEDICAL WELLNESS CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:STACY
Authorized Official - Middle Name:W
Authorized Official - Last Name:KIRKUM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:337-625-5050
Mailing Address - Street 1:1908 MAPLEWOOD DR
Mailing Address - Street 2:SUITE B
Mailing Address - City:SULPHUR
Mailing Address - State:LA
Mailing Address - Zip Code:70663-6000
Mailing Address - Country:US
Mailing Address - Phone:337-625-5050
Mailing Address - Fax:337-625-6726
Practice Address - Street 1:1908 MAPLEWOOD DR
Practice Address - Street 2:SUITE B
Practice Address - City:SULPHUR
Practice Address - State:LA
Practice Address - Zip Code:70663-6000
Practice Address - Country:US
Practice Address - Phone:337-625-5050
Practice Address - Fax:337-625-6726
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-27
Last Update Date:2011-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD14484R261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1476269Medicaid
LA1476269Medicaid