Provider Demographics
NPI:1740572395
Name:LAKE SIDE MEDICAL CENTER PROFESSIONAL. INC.
Entity Type:Organization
Organization Name:LAKE SIDE MEDICAL CENTER PROFESSIONAL. INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:KEITH
Authorized Official - Last Name:GAMBLE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-985-1221
Mailing Address - Street 1:10701 RIVERSIDE DR
Mailing Address - Street 2:SUITE 16
Mailing Address - City:TOLUCA LAKE
Mailing Address - State:CA
Mailing Address - Zip Code:91602-2384
Mailing Address - Country:US
Mailing Address - Phone:818-985-1221
Mailing Address - Fax:818-985-1222
Practice Address - Street 1:10701 RIVERSIDE DR
Practice Address - Street 2:SUITE 16
Practice Address - City:TOLUCA LAKE
Practice Address - State:CA
Practice Address - Zip Code:91602-2384
Practice Address - Country:US
Practice Address - Phone:818-985-1221
Practice Address - Fax:818-985-1222
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-13
Last Update Date:2011-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA76121174400000X
293D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
No293D00000XLaboratoriesPhysiological LaboratoryGroup - Multi-Specialty