Healthcare Provider Details

I. General information

NPI: 1356099790
Provider Name (Legal Business Name): LAKESIDE ORTHOPEDIC INSTITUTE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/15/2022
Last Update Date: 04/22/2026
Certification Date: 04/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1720 MESQUITE AVE STE 100
LAKE HAVASU CITY AZ
86403-5602
US

IV. Provider business mailing address

25 RIVIERA BLVD
LAKE HAVASU CITY AZ
86403-5694
US

V. Phone/Fax

Practice location:
  • Phone: 928-505-5555
  • Fax: 928-505-5557
Mailing address:
  • Phone: 928-505-5555
  • Fax: 928-505-5557

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: DANIEL EDWARD HEINER
Title or Position: AUTHORIZED OFFICIAL
Credential:
Phone: 928-505-5555