Provider Demographics
NPI:1700672045
Name:LAKESIDE RESIDENTIAL CARE INC
Entity type:Organization
Organization Name:LAKESIDE RESIDENTIAL CARE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:J
Authorized Official - Last Name:BAGLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-790-4162
Mailing Address - Street 1:PO BOX 874
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ID
Mailing Address - Zip Code:83501-0874
Mailing Address - Country:US
Mailing Address - Phone:208-790-4162
Mailing Address - Fax:
Practice Address - Street 1:605 JOSEPH AVE
Practice Address - Street 2:
Practice Address - City:WINCHESTER
Practice Address - State:ID
Practice Address - Zip Code:83555-5034
Practice Address - Country:US
Practice Address - Phone:208-790-4162
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-04-15
Last Update Date:2025-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility