Basic Information
| Provider Information | |||||||||
| NPI: | 1619985918 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LAKESIDE CARE CENTER LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | OAKDALE MANOR | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1025 N ADAMS RD | ||||||||
| Address2: | |||||||||
| City: | SAND SPRINGS | ||||||||
| State: | OK | ||||||||
| PostalCode: | 740638110 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9182455908 | ||||||||
| FaxNumber: | 9182453079 | ||||||||
| Practice Location | |||||||||
| Address1: | 1025 N ADAMS RD | ||||||||
| Address2: | |||||||||
| City: | SAND SPRINGS | ||||||||
| State: | OK | ||||||||
| PostalCode: | 740638110 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9182455908 | ||||||||
| FaxNumber: | 9182453079 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/03/2006 | ||||||||
| LastUpdateDate: | 04/13/2011 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | EISENMANN | ||||||||
| AuthorizedOfficialFirstName: | PATTY | ||||||||
| AuthorizedOfficialMiddleName: | JEAN | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 9185455908 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | ADMINISTRATOR | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 313M00000X | 20053290A | OK | Y | Nursing & Custodial Care Facilities | Nursing Facility/Intermediate Care Facility |
No ID Information.