Healthcare Provider Details

I. General information

NPI: 1790789170
Provider Name (Legal Business Name): GHC OF LAKESIDE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/13/2005
Last Update Date: 08/05/2024
Certification Date: 08/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11962 WOODSIDE AVE
LAKESIDE CA
92040-2914
US

IV. Provider business mailing address

11962 WOODSIDE AVE
LAKESIDE CA
92040-2914
US

V. Phone/Fax

Practice location:
  • Phone: 619-561-1222
  • Fax: 619-390-9487
Mailing address:
  • Phone: 619-561-1222
  • Fax: 619-390-9487

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number080000111
License Number StateCA

VIII. Authorized Official

Name: LOIS MASTROCOLA
Title or Position: CHIEF FINANCIAL OFFICER
Credential:
Phone: 714-241-5600