Provider Demographics
NPI:1841446804
Name:LAKESIDE CENTER
Entity type:Organization
Organization Name:LAKESIDE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:TREATMENT DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:RICH
Authorized Official - Middle Name:
Authorized Official - Last Name:SWINGER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-434-4535
Mailing Address - Street 1:13044 MARINE AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63146-2118
Mailing Address - Country:US
Mailing Address - Phone:314-434-4535
Mailing Address - Fax:314-434-9157
Practice Address - Street 1:13044 MARINE AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63146-2118
Practice Address - Country:US
Practice Address - Phone:314-434-4535
Practice Address - Fax:314-434-9157
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-11
Last Update Date:2008-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
No323P00000XResidential Treatment FacilitiesPsychiatric Residential Treatment Facility
No3245S0500XResidential Treatment FacilitiesSubstance Abuse Rehabilitation FacilitySubstance Abuse Treatment, Children