Provider Demographics
NPI:1780120006
Name:LAKESIDE SLEEP CENTER LLC
Entity type:Organization
Organization Name:LAKESIDE SLEEP CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CORTNIE
Authorized Official - Middle Name:
Authorized Official - Last Name:WELLMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:936-582-1112
Mailing Address - Street 1:123 BLUE HERON DR
Mailing Address - Street 2:STE 102
Mailing Address - City:MONTGOMERY
Mailing Address - State:TX
Mailing Address - Zip Code:77316-3192
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:123 BLUE HERON DR
Practice Address - Street 2:STE 102
Practice Address - City:MONTGOMERY
Practice Address - State:TX
Practice Address - Zip Code:77316-3192
Practice Address - Country:US
Practice Address - Phone:936-582-1112
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-10
Last Update Date:2017-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1000226332BX2000X
TX261QS1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS1200XAmbulatory Health Care FacilitiesClinic/CenterSleep Disorder Diagnostic
No332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies