Healthcare Provider Details

I. General information

NPI: 1013024314
Provider Name (Legal Business Name): LAKESIDE QUALITY HOME HEALTH CARE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/23/2006
Last Update Date: 03/04/2020
Certification Date: 03/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

109 S LAKE AVE
PAHOKEE FL
33476-1803
US

IV. Provider business mailing address

109 S LAKE AVE
PAHOKEE FL
33476-1803
US

V. Phone/Fax

Practice location:
  • Phone: 561-924-7675
  • Fax: 561-924-7677
Mailing address:
  • Phone: 561-924-7675
  • Fax: 561-924-7677

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number299992191
License Number StateFL

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier651221600
Identifier TypeMEDICAID
Identifier StateFL
Identifier Issuer

VIII. Authorized Official

Name: MS. NATALIA M ROQUE
Title or Position: PRESIDENT
Credential:
Phone: 561-924-7675