Basic Information
| Provider Information | |||||||||
| NPI: | 1538497060 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EASTSIDE OPERATING COMPANY LLC | ||||||||
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| OtherOrganizationName: | LAKE TERRACE HEALTH AND REHABILITATION | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1423 CLARKVIEW RD | ||||||||
| Address2: | SUITE 500 | ||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212092134 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4104272700 | ||||||||
| FaxNumber: | 4148155558 | ||||||||
| Practice Location | |||||||||
| Address1: | 2115 E WOODSTOCK PL | ||||||||
| Address2: | |||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532021342 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4103423155 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/20/2009 | ||||||||
| LastUpdateDate: | 06/10/2015 | ||||||||
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| AuthorizedOfficialLastName: | REYNOLDS | ||||||||
| AuthorizedOfficialFirstName: | BRIAN | ||||||||
| AuthorizedOfficialMiddleName: | K. | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 4105138738 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
No ID Information.