Healthcare Provider Details

I. General information

NPI: 1265666598
Provider Name (Legal Business Name): LAKESIDE ANESTHESIA SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/14/2009
Last Update Date: 05/14/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

520 N THIRD AVE
SANDPOINT ID
83864-1507
US

IV. Provider business mailing address

PO BOX 591
SAGLE ID
83860-0591
US

V. Phone/Fax

Practice location:
  • Phone: 208-263-1441
  • Fax:
Mailing address:
  • Phone: 208-265-3534
  • Fax: 208-265-3534

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRNA-671
License Number StateID

VIII. Authorized Official

Name: LORRAINE GRANFIELD
Title or Position: BUSINESS OWNER
Credential: CRNA
Phone: 772-285-3457