Provider Demographics
NPI:1356099790
Name:LAKESIDE ORTHOPEDIC INSTITUTE, LLC
Entity type:Organization
Organization Name:LAKESIDE ORTHOPEDIC INSTITUTE, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:HEINER
Authorized Official - Suffix:
Authorized Official - Credentials:
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:928-505-5557
Practice Address - Street 1:1720 MESQUITE AVE STE 100
Practice Address - Street 2:
Practice Address - City:LAKE HAVASU CITY
Practice Address - State:AZ
Practice Address - Zip Code:86403-5602
Practice Address - Country:US
Practice Address - Phone:928-505-5555
Practice Address - Fax:928-505-5557
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LAKESIDE ORTHOPEDIC INSTITUTE, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-03-15
Last Update Date:2024-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Single Specialty