Healthcare Provider Details

I. General information

NPI: 1093185928
Provider Name (Legal Business Name): LAKESIDE MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/05/2015
Last Update Date: 11/23/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

HIDALGO 244
CHAPALA MEXICO
45920
MX

IV. Provider business mailing address

PO BOX 108
BOWLING GREEN OH
43402-0108
US

V. Phone/Fax

Practice location:
  • Phone: 888-449-7799
  • Fax:
Mailing address:
  • Phone: 188-844-9779
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberDGP8902484
License Number StateZZ

VIII. Authorized Official

Name: MISS ANA RENTERIA ZAZUETA
Title or Position: OPERATIONS MANAGER-OWNER
Credential: ADMINISTRATOR
Phone: 888-449-7799