Provider Demographics
NPI:1710923651
Name:THE LAKESIDE CLINIC
Entity Type:Organization
Organization Name:THE LAKESIDE CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:JAYNE
Authorized Official - Middle Name:
Authorized Official - Last Name:CULBERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-937-2134
Mailing Address - Street 1:PO BOX 110
Mailing Address - Street 2:38843 DEXTER ROAD
Mailing Address - City:DEXTER
Mailing Address - State:OR
Mailing Address - Zip Code:97431-0110
Mailing Address - Country:US
Mailing Address - Phone:541-937-2134
Mailing Address - Fax:541-937-1370
Practice Address - Street 1:38843 DEXTER RD
Practice Address - Street 2:
Practice Address - City:DEXTER
Practice Address - State:OR
Practice Address - Zip Code:97431-9775
Practice Address - Country:US
Practice Address - Phone:541-937-2134
Practice Address - Fax:541-937-1370
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-21
Last Update Date:2009-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR084054259N1261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR122416Medicaid
ORW20367Medicare UPIN
OR122416Medicaid