MEDICARE: GHC OF LAKESIDE, 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	314000000X	Skilled Nursing Facility	080000111	CA

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	:	1790789170
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GHC OF LAKESIDE, LLC

Provider Business Mailing Address
First Line	:	11962 WOODSIDE AVE
Second Line	:
City	:	LAKESIDE
State	:	CA
Zip	:	92040-2914
Country	:	US
Telephone Number	:	619-561-1222
Fax Number	:	619-390-9487

Provider Business Practice Location Address
First Line	:	11962 WOODSIDE AVE
Second Line	:
City	:	LAKESIDE
State	:	CA
Zip	:	92040-2914
Country	:	US
Telephone Number	:	619-561-1222
Fax Number	:	619-390-9487

Authorized Official
Title or Position	:	CHIEF FINANCIAL OFFICER
Name	:	LOIS MASTROCOLA
Credential	:
Telephone Number	:	714-241-5600

Provider Enumeration Date	:	06/13/2005
Last Update Date	:	08/05/2024

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Directions to “GHC OF LAKESIDE, LLC ” Practice Location

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