Basic Information
| Provider Information | |||||||||
| NPI: | 1801885413 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DISTRICT HOSPITAL HOLDINGS INC | ||||||||
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| OtherOrganizationName: | LAKESIDE MEDICAL CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1515 N FLAGLER DR STE 101 | ||||||||
| Address2: | |||||||||
| City: | WEST PALM BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334013429 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5616591270 | ||||||||
| FaxNumber: | 5618045629 | ||||||||
| Practice Location | |||||||||
| Address1: | 39200 HOOKER HWY | ||||||||
| Address2: | |||||||||
| City: | BELLE GLADE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33430 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5619966571 | ||||||||
| FaxNumber: | 5619962898 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/17/2005 | ||||||||
| LastUpdateDate: | 08/22/2018 | ||||||||
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| AuthorizedOfficialLastName: | DAVIS | ||||||||
| AuthorizedOfficialFirstName: | DARCY | ||||||||
| AuthorizedOfficialMiddleName: | J. | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 5616591270 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282NR1301X | 3992 | FL | Y | Hospitals | General Acute Care Hospital | Rural |
ID Information
| ID | Type | State | Issuer | Description | 010144300 | 05 | FL | MEDICAID | 227 | 01 | FL | BLUE CROSS | OTHER |