MEDICARE: LAKESIDE AUDIOLOGY 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	231H00000X	Audiologist
2	235Z00000X	Speech-Language Pathologist
3	261QH0700X	Hearing and Speech Clinic/Center	9758	NC
4	261QH0700X	Hearing and Speech Clinic/Center	4011	SC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1417341280
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LAKESIDE AUDIOLOGY LLC

Provider Business Mailing Address
First Line	:	870 GOLD HILL RD STE 104
Second Line	:
City	:	FORT MILL
State	:	SC
Zip	:	29708-8988
Country	:	US
Telephone Number	:	803-620-8250
Fax Number	:	803-638-6901

Provider Business Practice Location Address
First Line	:	870 GOLD HILL RD STE 104
Second Line	:
City	:	FORT MILL
State	:	SC
Zip	:	29708-8988
Country	:	US
Telephone Number	:	803-620-8250
Fax Number	:	803-638-6901

Authorized Official
Title or Position	:	DOCTOR OF AUDIOLOGY
Name	:	KIMBERLY BLOCK
Credential	:	AUD
Telephone Number	:	803-412-6789

Provider Enumeration Date	:	03/19/2015
Last Update Date	:	11/19/2021

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Directions to “LAKESIDE AUDIOLOGY LLC ” Practice Location

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