Provider Demographics
NPI:1972373710
Name:LAKESIDE ORTHOPEDIC INSTITUTE LLC
Entity Type:Organization
Organization Name:LAKESIDE ORTHOPEDIC INSTITUTE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:HEINER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:928-505-5555
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:928-505-5555
Mailing Address - Fax:
Practice Address - Street 1:1944 MESQUITE AVE
Practice Address - Street 2:
Practice Address - City:LAKE HAVASU CITY
Practice Address - State:AZ
Practice Address - Zip Code:86403-5729
Practice Address - Country:US
Practice Address - Phone:928-505-5555
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LAKESIDE ORTHOPEDIC INSTITUTE LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2024-01-03
Last Update Date:2024-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care