1265666598 NPI number — LAKESIDE ANESTHESIA SERVICES

Table of content: LINDA JO SIMMONS MHPP (NPI 1154631828)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265666598 NPI number — LAKESIDE ANESTHESIA SERVICES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LAKESIDE ANESTHESIA SERVICES
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1265666598
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/14/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 591
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAGLE
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83860-0591
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-265-3534
Provider Business Mailing Address Fax Number:
208-265-3534

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
520 N THIRD AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SANDPOINT
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83864-1507
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-263-1441
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/14/2009

Additional Information

Authorized Official

Authorized Official Last Name:
GRANFIELD
Authorized Official First Name:
LORRAINE
Authorized Official Middle Name:
Authorized Official Title or Position:
BUSINESS OWNER
Authorized Official Telephone Number:
772-285-3457

Provider Taxonomy Codes

  • Taxonomy code: 367500000X , with the licence number:  RNA-671 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: APPLYING . This is a "APPLYING FOR ALL PROVIDER NUMBERS" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".




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