Provider Demographics
NPI:1770777872
Name:LAKESIDE UNION
Entity type:Organization
Organization Name:LAKESIDE UNION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DEPUTY SUPERINTENDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:KAMRAN
Authorized Official - Middle Name:
Authorized Official - Last Name:AZIMZADEH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:619-390-2614
Mailing Address - Street 1:12335 WOODSIDE AVE
Mailing Address - Street 2:
Mailing Address - City:LAKESIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92040-3015
Mailing Address - Country:US
Mailing Address - Phone:619-390-2620
Mailing Address - Fax:619-390-2597
Practice Address - Street 1:12335 WOODSIDE AVE
Practice Address - Street 2:
Practice Address - City:LAKESIDE
Practice Address - State:CA
Practice Address - Zip Code:92040-3015
Practice Address - Country:US
Practice Address - Phone:619-390-2620
Practice Address - Fax:619-390-2597
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-31
Last Update Date:2007-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA251300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251300000XAgenciesLocal Education Agency (LEA)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASS3768189Medicaid