Provider Demographics
NPI:1659738623
Name:LAKERIDGE CARE MANAGEMENT
Entity Type:Organization
Organization Name:LAKERIDGE CARE MANAGEMENT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR CASE MANAGEMENT PROGRAM
Authorized Official - Prefix:MS
Authorized Official - First Name:DEMETRIA
Authorized Official - Middle Name:GAYLE
Authorized Official - Last Name:WALLACE
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:1866-386-8404
Mailing Address - Street 1:2635 VILLA DI LAGO UNIT 4
Mailing Address - Street 2:
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75054-6630
Mailing Address - Country:US
Mailing Address - Phone:186-638-6840
Mailing Address - Fax:866-386-8404
Practice Address - Street 1:2635 VILLA DI LAGO UNIT 4
Practice Address - Street 2:
Practice Address - City:GRAND PRAIRIE
Practice Address - State:TX
Practice Address - Zip Code:75054-6630
Practice Address - Country:US
Practice Address - Phone:186-638-6840
Practice Address - Fax:866-386-8404
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-21
Last Update Date:2016-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management