Provider Demographics
NPI:1134722820
Name:LAKESIDE TLF, LLC
Entity type:Organization
Organization Name:LAKESIDE TLF, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:DR
Authorized Official - First Name:MANEESH
Authorized Official - Middle Name:
Authorized Official - Last Name:BANSAL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:800-697-5390
Mailing Address - Street 1:10866 WASHINGTON BLVD STE 42
Mailing Address - Street 2:
Mailing Address - City:CULVER CITY
Mailing Address - State:CA
Mailing Address - Zip Code:90232-3610
Mailing Address - Country:US
Mailing Address - Phone:213-986-8416
Mailing Address - Fax:
Practice Address - Street 1:1962 VANDOLAH RD
Practice Address - Street 2:
Practice Address - City:WAUCHULA
Practice Address - State:FL
Practice Address - Zip Code:33873-8726
Practice Address - Country:US
Practice Address - Phone:800-697-5390
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-11-17
Last Update Date:2020-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes283X00000XHospitalsRehabilitation Hospital
No320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
No320700000XResidential Treatment FacilitiesResidential Treatment Facility, Physical Disabilities
No322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children