1992162879 NPI number — LAKESIDE CLINIC, LLC

Table of content: (NPI 1992162879)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1992162879 NPI number — LAKESIDE CLINIC, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LAKESIDE CLINIC, LLC
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:
MEDMARK TREATMENT CENTERS CLEARWATER
Provider Other Organization Name Type Code:
3
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:
1992162879
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/29/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1720 LAKEPOINTE DR STE 117
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LEWISVILLE
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75057-6425
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
469-470-4779
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
13700 58TH ST N
Provider Second Line Business Practice Location Address:
BUILDING 2, SUITE 201
Provider Business Practice Location Address City Name:
CLEARWATER
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33760-3757
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
727-223-3545
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/22/2016

Additional Information

Authorized Official

Authorized Official Last Name:
JARVIE
Authorized Official First Name:
BRUCE
Authorized Official Middle Name:
Authorized Official Title or Position:
VP, TREASURER
Authorized Official Telephone Number:
214-379-3300

Provider Taxonomy Codes

  • Taxonomy code: 251S00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QM2800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 261QR0405X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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





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