Provider Demographics
NPI:1750651568
Name:LAKESIDE RECOVERY CENTER
Entity Type:Organization
Organization Name:LAKESIDE RECOVERY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIR OF TREATMENT SERVICE
Authorized Official - Prefix:MS
Authorized Official - First Name:PHYLLIS
Authorized Official - Middle Name:
Authorized Official - Last Name:WEINSTEIN
Authorized Official - Suffix:
Authorized Official - Credentials:MSW,MED,LCSW,LPC,LCA
Authorized Official - Phone:856-302-1362
Mailing Address - Street 1:200 INDEPENDENCE BLVD
Mailing Address - Street 2:
Mailing Address - City:SICKLERVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:08081-1092
Mailing Address - Country:US
Mailing Address - Phone:856-302-1362
Mailing Address - Fax:
Practice Address - Street 1:200 INDEPENDENCE BLVD
Practice Address - Street 2:
Practice Address - City:SICKLERVILLE
Practice Address - State:NJ
Practice Address - Zip Code:08081-1092
Practice Address - Country:US
Practice Address - Phone:856-302-1362
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-10
Last Update Date:2013-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ2000527-11261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center