Healthcare Provider Details

I. General information

NPI: 1043200355
Provider Name (Legal Business Name): LAKESIDE MEDICAL CENTER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/27/2005
Last Update Date: 03/27/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

129 6TH AVE SE
PINE CITY MN
55063-1913
US

IV. Provider business mailing address

129 6TH AVE SE
PINE CITY MN
55063-1913
US

V. Phone/Fax

Practice location:
  • Phone: 320-629-2542
  • Fax: 320-629-1093
Mailing address:
  • Phone: 320-629-2542
  • Fax: 320-629-1093

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number State

VIII. Authorized Official

Name: MR. RICHARD ALLEN MCMAHON
Title or Position: CFO
Credential:
Phone: 320-629-2542