Provider Demographics
NPI:1477657823
Name:LAKESIDE CLINIC LLC
Entity Type:Organization
Organization Name:LAKESIDE CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:CAROLYN
Authorized Official - Middle Name:H
Authorized Official - Last Name:MASON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:256-582-5131
Mailing Address - Street 1:2337 HOMER CLAYTON DRIVE
Mailing Address - Street 2:
Mailing Address - City:GUNTERSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35976
Mailing Address - Country:US
Mailing Address - Phone:256-582-5131
Mailing Address - Fax:256-582-1100
Practice Address - Street 1:2337 HOMER CLAYTON DRIVE
Practice Address - Street 2:
Practice Address - City:GUNTERSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35976
Practice Address - Country:US
Practice Address - Phone:256-582-5131
Practice Address - Fax:256-582-1100
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-07
Last Update Date:2024-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Not Answered207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
23185OtherREED-JOHNSON AL LIC NUMB
051550006OtherBOGGESS PROVIDER NUMBER
051509352OtherREED-JOHNSON PROVIDER NUM
051518706OtherFOLEY PROVIDER NUMBER
22839OtherNIXON AL LIC NUMBER
9801OtherBOGGESS AL LIC NUMBER
051502549OtherNIXON PROVIDER NUMBER
10014OtherLARSON AL LIC NUMBER
051550004OtherLARSON PROVIDER NUMBER
25574OtherFOLEY AL LIC NUMBER
BN6032750OtherNIXON DEA NUMBER
9801OtherBOGGESS AL LIC NUMBER
E82279Medicare UPIN
C72002Medicare UPIN
25574OtherFOLEY AL LIC NUMBER