Basic Information
| Provider Information | |||||||||
| NPI: | 1336492495 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LAKESIDE HEALTH CLINIC, P.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1269 | ||||||||
| Address2: | |||||||||
| City: | PARIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 382421269 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7319242000 | ||||||||
| FaxNumber: | 7316530053 | ||||||||
| Practice Location | |||||||||
| Address1: | 813 E WOOD ST | ||||||||
| Address2: | |||||||||
| City: | PARIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 382424223 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7319242000 | ||||||||
| FaxNumber: | 7316530053 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/25/2012 | ||||||||
| LastUpdateDate: | 03/18/2021 | ||||||||
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| AuthorizedOfficialLastName: | HUBBARD | ||||||||
| AuthorizedOfficialFirstName: | LISA | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER/PA-C | ||||||||
| AuthorizedOfficialTelephone: | 7319242000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | PA-C | ||||||||
| NPICertificationDate: | 03/18/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 1530820 | 05 | TN | MEDICAID |