Basic Information
| Provider Information | |||||||||
| NPI: | 1679855498 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BAYSIDE LODGE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1450 S LAPEER RD | ||||||||
| Address2: | |||||||||
| City: | OXFORD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483716108 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2489699932 | ||||||||
| FaxNumber: | 2489693006 | ||||||||
| Practice Location | |||||||||
| Address1: | 2700 W GENESEE AVE | ||||||||
| Address2: | |||||||||
| City: | SAGINAW | ||||||||
| State: | MI | ||||||||
| PostalCode: | 486023723 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9897991266 | ||||||||
| FaxNumber: | 9897991548 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/19/2011 | ||||||||
| LastUpdateDate: | 12/03/2013 | ||||||||
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| AuthorizedOfficialLastName: | KISS WILSON | ||||||||
| AuthorizedOfficialFirstName: | JACQULINE | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 2489699932 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | TRAINING AND TREATMENT INNOVATIONS INC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | Y | Agencies | Community/Behavioral Health |
No ID Information.