MEDICARE: ELEMENTS AT LAKEWOOD, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	324500000X	Substance Abuse Rehabilitation Facility

General Provider Information

NPI Number	:	1073238572
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ELEMENTS AT LAKEWOOD, LLC

Provider Business Mailing Address
First Line	:	1700 CEDAR SPRINGS ROAD
Second Line	:	APT 1304
City	:	DALLAS
State	:	TX
Zip	:	75202
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	6205 LA VISTA DRIVE
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75214-4312
Country	:	US
Telephone Number	:	646-509-7035
Fax Number	:

Authorized Official
Title or Position	:	MEMBER
Name	:	BRIAN BAUER
Credential	:
Telephone Number	:	605-351-1886

Provider Enumeration Date	:	10/06/2022
Last Update Date	:	10/06/2022

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Directions to “ELEMENTS AT LAKEWOOD, LLC ” Practice Location

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