Provider Demographics
NPI:1538497060
Name:EASTSIDE OPERATING COMPANY LLC
Entity Type:Organization
Organization Name:EASTSIDE OPERATING COMPANY LLC
Other - Org Name:LAKE TERRACE HEALTH AND REHABILITATION
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:K
Authorized Official - Last Name:REYNOLDS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:410-513-8738
Mailing Address - Street 1:1423 CLARKVIEW RD
Mailing Address - Street 2:SUITE 500
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21209-2134
Mailing Address - Country:US
Mailing Address - Phone:410-427-2700
Mailing Address - Fax:414-815-5558
Practice Address - Street 1:2115 E WOODSTOCK PL
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53202-1342
Practice Address - Country:US
Practice Address - Phone:410-342-3155
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-20
Last Update Date:2015-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA555863Medicare Oscar/Certification