Healthcare Provider Details

I. General information

NPI: 1598848277
Provider Name (Legal Business Name): LAKESIDE CRISIS STABILIZATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/24/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 DOT BARN RD
BLOOMINGDALE GA
31302-9353
US

IV. Provider business mailing address

600 DOT BARN RD
BLOOMINGDALE GA
31302-9353
US

V. Phone/Fax

Practice location:
  • Phone: 912-330-8335
  • Fax: 912-330-8340
Mailing address:
  • Phone: 912-330-8335
  • Fax: 912-330-8340

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License Number
License Number StateGA

VIII. Authorized Official

Name: CHARLES LI
Title or Position: RHA
Credential:
Phone: 912-356-2011