Provider Demographics
NPI:1598848277
Name:LAKESIDE CRISIS STABILIZATION
Entity Type:Organization
Organization Name:LAKESIDE CRISIS STABILIZATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:RHA
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:
Authorized Official - Last Name:LI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:912-356-2011
Mailing Address - Street 1:600 DOT BARN RD
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGDALE
Mailing Address - State:GA
Mailing Address - Zip Code:31302-9353
Mailing Address - Country:US
Mailing Address - Phone:912-330-8335
Mailing Address - Fax:912-330-8340
Practice Address - Street 1:600 DOT BARN RD
Practice Address - Street 2:
Practice Address - City:BLOOMINGDALE
Practice Address - State:GA
Practice Address - Zip Code:31302-9353
Practice Address - Country:US
Practice Address - Phone:912-330-8335
Practice Address - Fax:912-330-8340
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children