Healthcare Provider Details

I. General information

NPI: 1679764229
Provider Name (Legal Business Name): LAKESIDE ORTHOPEDIC INSTITUTE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/08/2007
Last Update Date: 04/22/2026
Certification Date: 04/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25 RIVIERA BLVD
LAKE HAVASU CITY AZ
86403-5694
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:
Mailing address:
  • Phone: 928-505-5555
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code2471M1202X
TaxonomyMagnetic Resonance Imaging Radiologic Technologist
License Number
License Number State

VIII. Authorized Official

Name: DANIEL EDWARD HEINER
Title or Position: PARTNER
Credential: MD
Phone: 928-505-5555