Healthcare Provider Details

I. General information

NPI: 1811804362
Provider Name (Legal Business Name): LAKESIDE RTC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/27/2026
Last Update Date: 08/28/2026
Certification Date: 08/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1962 VANDOLAH RD
WAUCHULA FL
33873-8726
US

IV. Provider business mailing address

1962 VANDOLAH RD
WAUCHULA FL
33873-8726
US

V. Phone/Fax

Practice location:
  • Phone: 863-773-2857
  • Fax:
Mailing address:
  • Phone: 863-773-2857
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code283X00000X
TaxonomyRehabilitation Hospital
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code320700000X
TaxonomyPhysical Disabilities Residential Treatment Facility
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: MS. ELIZABETH CHOQUETTE
Title or Position: BOM
Credential:
Phone: 863-451-6632