Provider Demographics
NPI:1417341280
Name:LAKESIDE AUDIOLOGY LLC
Entity Type:Organization
Organization Name:LAKESIDE AUDIOLOGY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR OF AUDIOLOGY
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:
Authorized Official - Last Name:BLOCK
Authorized Official - Suffix:
Authorized Official - Credentials:AUD
Authorized Official - Phone:803-412-6789
Mailing Address - Street 1:870 GOLD HILL RD STE 104
Mailing Address - Street 2:
Mailing Address - City:FORT MILL
Mailing Address - State:SC
Mailing Address - Zip Code:29708-8988
Mailing Address - Country:US
Mailing Address - Phone:803-620-8250
Mailing Address - Fax:803-638-6901
Practice Address - Street 1:870 GOLD HILL RD STE 104
Practice Address - Street 2:
Practice Address - City:FORT MILL
Practice Address - State:SC
Practice Address - Zip Code:29708-8988
Practice Address - Country:US
Practice Address - Phone:803-620-8250
Practice Address - Fax:803-638-6901
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-19
Last Update Date:2021-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
231H00000X, 235Z00000X
SC4011261QH0700X
NC9758261QH0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QH0700XAmbulatory Health Care FacilitiesClinic/CenterHearing and Speech
No231H00000XSpeech, Language and Hearing Service ProvidersAudiologistGroup - Single Specialty
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCSA1525Medicaid
NCQ39159AMedicare PIN