Provider Demographics
NPI:1639682438
Name:SOBRIETY SOLUTIONS LAKESIDE LLC
Entity Type:Organization
Organization Name:SOBRIETY SOLUTIONS LAKESIDE LLC
Other - Org Name:LAKESIDE RECOVERY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:
Authorized Official - Last Name:PETTIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:856-302-1362
Mailing Address - Street 1:200 INDEPENDENCE BLVD
Mailing Address - Street 2:
Mailing Address - City:SICKLERVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:08081-1092
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:900 LIBERTY PL
Practice Address - Street 2:
Practice Address - City:SICKLERVILLE
Practice Address - State:NJ
Practice Address - Zip Code:08081-5716
Practice Address - Country:US
Practice Address - Phone:856-302-1362
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-15
Last Update Date:2023-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ2000667261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ2000667OtherSTATE OF NJ