Provider Demographics
NPI:1619985918
Name:LAKESIDE CARE CENTER LLC
Entity Type:Organization
Organization Name:LAKESIDE CARE CENTER LLC
Other - Org Name:OAKDALE MANOR
Other - Org Type:Other Name
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:PATTY
Authorized Official - Middle Name:JEAN
Authorized Official - Last Name:EISENMANN
Authorized Official - Suffix:
Authorized Official - Credentials:ADMINISTRATOR
Authorized Official - Phone:918-545-5908
Mailing Address - Street 1:1025 N ADAMS RD
Mailing Address - Street 2:
Mailing Address - City:SAND SPRINGS
Mailing Address - State:OK
Mailing Address - Zip Code:74063-8110
Mailing Address - Country:US
Mailing Address - Phone:918-245-5908
Mailing Address - Fax:918-245-3079
Practice Address - Street 1:1025 N ADAMS RD
Practice Address - Street 2:
Practice Address - City:SAND SPRINGS
Practice Address - State:OK
Practice Address - Zip Code:74063-8110
Practice Address - Country:US
Practice Address - Phone:918-245-5908
Practice Address - Fax:918-245-3079
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-03
Last Update Date:2011-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK20053290A313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK375285Medicare ID - Type Unspecified