Provider Demographics
NPI:1972287829
Name:LAKESIDE FOOT & ANKLE LLC
Entity Type:Organization
Organization Name:LAKESIDE FOOT & ANKLE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:HASELSBERGER
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:336-339-9603
Mailing Address - Street 1:50 SQUARE DR STE 1000
Mailing Address - Street 2:
Mailing Address - City:VICTOR
Mailing Address - State:NY
Mailing Address - Zip Code:14564-1062
Mailing Address - Country:US
Mailing Address - Phone:585-233-3826
Mailing Address - Fax:
Practice Address - Street 1:50 SQUARE DR STE 1000
Practice Address - Street 2:
Practice Address - City:VICTOR
Practice Address - State:NY
Practice Address - Zip Code:14564-1062
Practice Address - Country:US
Practice Address - Phone:585-233-3826
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-06-12
Last Update Date:2023-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP1100XAmbulatory Health Care FacilitiesClinic/CenterPodiatric