Provider Demographics
NPI:1720179070
Name:LAKESIDE QUALITY HOME HEALTH CARE, INC.
Entity Type:Organization
Organization Name:LAKESIDE QUALITY HOME HEALTH CARE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:MS
Authorized Official - First Name:NATALIA
Authorized Official - Middle Name:M
Authorized Official - Last Name:ROQUE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:561-924-7675
Mailing Address - Street 1:485 WEST MAIN ST,
Mailing Address - Street 2:SUITE A
Mailing Address - City:PAHOKEE
Mailing Address - State:FL
Mailing Address - Zip Code:33476-2405
Mailing Address - Country:US
Mailing Address - Phone:561-924-7675
Mailing Address - Fax:561-924-7677
Practice Address - Street 1:485 WEST MAIN ST,
Practice Address - Street 2:SUITE A
Practice Address - City:PAHOKEE
Practice Address - State:FL
Practice Address - Zip Code:33476-2405
Practice Address - Country:US
Practice Address - Phone:561-924-7675
Practice Address - Fax:561-924-7677
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-28
Last Update Date:2010-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL299992191251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL651221600Medicaid
FL10-8327Medicare ID - Type Unspecified