Provider Demographics
NPI:1437156171
Name:SENIOR HEALTH-LAKESIDE, LLC
Entity Type:Organization
Organization Name:SENIOR HEALTH-LAKESIDE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:SHANNON
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:JANTZEN
Authorized Official - Suffix:
Authorized Official - Credentials:LNFA
Authorized Official - Phone:806-793-2555
Mailing Address - Street 1:4306 24TH ST
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79410-1818
Mailing Address - Country:US
Mailing Address - Phone:806-793-2555
Mailing Address - Fax:806-793-9835
Practice Address - Street 1:4306 24TH ST
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79410-1818
Practice Address - Country:US
Practice Address - Phone:806-793-2555
Practice Address - Fax:806-793-9835
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-07
Last Update Date:2007-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX4622314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility