Provider Demographics
NPI:1750618419
Name:LAKESIDE FOR CHILDREN
Entity type:Organization
Organization Name:LAKESIDE FOR CHILDREN
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:BOARD ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:DON
Authorized Official - Middle Name:
Authorized Official - Last Name:NITZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:269-381-4760
Mailing Address - Street 1:3921 OAKLAND DR
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49008-4819
Mailing Address - Country:US
Mailing Address - Phone:269-381-4760
Mailing Address - Fax:
Practice Address - Street 1:3921 OAKLAND DR
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49008-4819
Practice Address - Country:US
Practice Address - Phone:269-381-4760
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-17
Last Update Date:2009-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI6357061OtherSTATE OF MICHIGAN RESIDENTIAL PROVIDER NUMBER