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NPI Code Detail

MEDICARE: LAKESIDE ORTHOPEDIC INSTITUTE LLC

MEDICARE: LAKESIDE ORTHOPEDIC INSTITUTE 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
1208VP0014XInterventional Pain Medicine Physician
2225100000XPhysical Therapist
32471M1202XMagnetic Resonance Imaging Radiologic Technologist
4207X00000XOrthopaedic Surgery Physician

Medicare Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1DF0357OTHERAZMEDICARE RAILROAD

General Provider Information

NPI Number : 1679764229
Entity Type Code : Organization
Provider Name (Legal Business Name) : LAKESIDE ORTHOPEDIC INSTITUTE LLC
Provider Business Mailing Address
First Line : 25 RIVIERA BLVD
Second Line :
City : LAKE HAVASU CITY
State : AZ
Zip : 86403-5694
Country : US
Telephone Number : 928-505-5555
Fax Number :
Provider Business Practice Location Address
First Line : 25 RIVIERA BLVD
Second Line :
City : LAKE HAVASU CITY
State : AZ
Zip : 86403-5694
Country : US
Telephone Number : 928-505-5555
Fax Number :
Authorized Official
Title or Position : PARTNER
Name : DANIEL EDWARD HEINER
Credential : MD
Telephone Number : 928-505-5555
Provider Enumeration Date : 08/08/2007
Last Update Date : 08/17/2021

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Directions to “LAKESIDE ORTHOPEDIC INSTITUTE LLC ” Practice Location

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