Provider Demographics
NPI:1689832016
Name:LAKESIDE MEDICAL
Entity Type:Organization
Organization Name:LAKESIDE MEDICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ISAIAH
Authorized Official - Middle Name:
Authorized Official - Last Name:TANNACI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:775-265-4072
Mailing Address - Street 1:1482 IRENE CT
Mailing Address - Street 2:
Mailing Address - City:GARDNERVILLE
Mailing Address - State:NV
Mailing Address - Zip Code:89460-8205
Mailing Address - Country:US
Mailing Address - Phone:775-265-4072
Mailing Address - Fax:775-265-4062
Practice Address - Street 1:1482 IRENE CT
Practice Address - Street 2:
Practice Address - City:GARDNERVILLE
Practice Address - State:NV
Practice Address - Zip Code:89460-8205
Practice Address - Country:US
Practice Address - Phone:775-265-4072
Practice Address - Fax:775-265-4062
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-02
Last Update Date:2008-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies