Provider Demographics
NPI:1790789170
Name:GHC OF LAKESIDE, LLC
Entity Type:Organization
Organization Name:GHC OF LAKESIDE, LLC
Other - Org Name:LAKESIDE SPECIAL CARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:LOIS
Authorized Official - Middle Name:
Authorized Official - Last Name:MASTROCOLA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:714-241-5600
Mailing Address - Street 1:11962 WOODSIDE AVE
Mailing Address - Street 2:
Mailing Address - City:LAKESIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92040-2914
Mailing Address - Country:US
Mailing Address - Phone:619-561-1222
Mailing Address - Fax:619-390-9487
Practice Address - Street 1:11962 WOODSIDE AVE
Practice Address - Street 2:
Practice Address - City:LAKESIDE
Practice Address - State:CA
Practice Address - Zip Code:92040-2914
Practice Address - Country:US
Practice Address - Phone:619-561-1222
Practice Address - Fax:619-390-9487
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-13
Last Update Date:2022-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA080000111314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZT18594HMedicaid
CAZZT18594HMedicaid