Provider Demographics
NPI:1962636050
Name:LAKESIDE ORTHOPEDIC INSTITUTE, LLC
Entity Type:Organization
Organization Name:LAKESIDE ORTHOPEDIC INSTITUTE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WESLEY
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:9288-545-5555
Mailing Address - Street 1:25 RIVIERA BLVD
Mailing Address - Street 2:
Mailing Address - City:LAKE HAVASU CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86403-5694
Mailing Address - Country:US
Mailing Address - Phone:928-854-5555
Mailing Address - Fax:928-854-5573
Practice Address - Street 1:1979 MCCULLOCH BLVD N
Practice Address - Street 2:SUITE 101
Practice Address - City:LAKE HAVASU CITY
Practice Address - State:AZ
Practice Address - Zip Code:86403-0953
Practice Address - Country:US
Practice Address - Phone:928-855-4842
Practice Address - Fax:928-855-7452
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-05
Last Update Date:2009-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2641225100000X
AZ8192225100000X
AZ6762225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ110835Medicare PIN