Provider Demographics
NPI:1891791927
Name:LAKESIDE BEIKIRCH CARE CENTER, INC.
Entity Type:Organization
Organization Name:LAKESIDE BEIKIRCH CARE CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:
Authorized Official - Last Name:KLINETOB
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:585-395-6095
Mailing Address - Street 1:170 WEST AVE
Mailing Address - Street 2:
Mailing Address - City:BROCKPORT
Mailing Address - State:NY
Mailing Address - Zip Code:14420-1227
Mailing Address - Country:US
Mailing Address - Phone:585-395-6052
Mailing Address - Fax:585-395-6007
Practice Address - Street 1:170 WEST AVE
Practice Address - Street 2:
Practice Address - City:BROCKPORT
Practice Address - State:NY
Practice Address - Zip Code:14420-1227
Practice Address - Country:US
Practice Address - Phone:585-395-6052
Practice Address - Fax:585-395-6007
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-23
Last Update Date:2015-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2752301N261QH0700X, 314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No261QH0700XAmbulatory Health Care FacilitiesClinic/CenterHearing and Speech
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY106288CIOtherPREFERRED CARE
NYCNOtherEXCELLUS
NY01137113Medicaid
NYCNOtherEXCELLUS