Basic Information
| Provider Information | |||||||||
| NPI: | 1518953892 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LAKESIDE NURSING AND REHABILITATION CENTER, INC. | ||||||||
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| OtherOrganizationName: | LAKESIDE NURSING CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1207 WILLOW RUN ROAD | ||||||||
| Address2: | |||||||||
| City: | LAKE CITY | ||||||||
| State: | AR | ||||||||
| PostalCode: | 724370578 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8702378151 | ||||||||
| FaxNumber: | 8702374011 | ||||||||
| Practice Location | |||||||||
| Address1: | 1207 WILLOW RUN ROAD | ||||||||
| Address2: | |||||||||
| City: | LAKE CITY | ||||||||
| State: | AR | ||||||||
| PostalCode: | 724370578 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8702378151 | ||||||||
| FaxNumber: | 8702374011 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/22/2005 | ||||||||
| LastUpdateDate: | 11/12/2014 | ||||||||
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| AuthorizedOfficialLastName: | ADAMS | ||||||||
| AuthorizedOfficialFirstName: | A | ||||||||
| AuthorizedOfficialMiddleName: | BRANDON | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5019320050 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 670 | AR | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 119578311 | 05 | AR | MEDICAID |