Provider Demographics
NPI:1396779542
Name:LAKESIDE COMPREHENSIVE REHABILITATION INC.
Entity type:Organization
Organization Name:LAKESIDE COMPREHENSIVE REHABILITATION INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/O.T.R.L
Authorized Official - Prefix:MRS
Authorized Official - First Name:DEBORAH
Authorized Official - Middle Name:
Authorized Official - Last Name:WINDELL
Authorized Official - Suffix:
Authorized Official - Credentials:OTRL
Authorized Official - Phone:231-873-3577
Mailing Address - Street 1:601 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:HART
Mailing Address - State:MI
Mailing Address - Zip Code:49420-1144
Mailing Address - Country:US
Mailing Address - Phone:231-873-3577
Mailing Address - Fax:231-873-3557
Practice Address - Street 1:601 E MAIN ST
Practice Address - Street 2:
Practice Address - City:HART
Practice Address - State:MI
Practice Address - Zip Code:49420-1144
Practice Address - Country:US
Practice Address - Phone:231-873-3577
Practice Address - Fax:231-873-3557
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-11
Last Update Date:2015-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0704110OtherUNITED HEALTHCARE GROUP #
MI177403453814OtherHUMANA ID
MI650F410300OtherBCBSM PIN
MI0007770495OtherAETNA PIN
MI0N79320Medicare PIN