Provider Demographics
NPI:1679855498
Name:BAYSIDE LODGE
Entity Type:Organization
Organization Name:BAYSIDE LODGE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JACQULINE
Authorized Official - Middle Name:
Authorized Official - Last Name:KISS WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-969-9932
Mailing Address - Street 1:1450 S LAPEER RD
Mailing Address - Street 2:
Mailing Address - City:OXFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48371-6108
Mailing Address - Country:US
Mailing Address - Phone:248-969-9932
Mailing Address - Fax:248-969-3006
Practice Address - Street 1:2700 W GENESEE AVE
Practice Address - Street 2:
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48602-3723
Practice Address - Country:US
Practice Address - Phone:989-799-1266
Practice Address - Fax:989-799-1548
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TRAINING AND TREATMENT INNOVATIONS INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-09-19
Last Update Date:2013-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health