Provider Demographics
NPI:1902040223
Name:LAKESIDE SENIOR CARE LLC
Entity Type:Organization
Organization Name:LAKESIDE SENIOR CARE LLC
Other - Org Name:LAKESIDE REHABILITATION AND CARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KERI
Authorized Official - Middle Name:
Authorized Official - Last Name:POWELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:806-793-2555
Mailing Address - Street 1:930 RIDGEBROOK RD
Mailing Address - Street 2:
Mailing Address - City:SPARKS
Mailing Address - State:MD
Mailing Address - Zip Code:21152-9390
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4306 24TH ST
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79410-1818
Practice Address - Country:US
Practice Address - Phone:806-793-2555
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-30
Last Update Date:2009-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility