Healthcare Provider Details

I. General information

NPI: 1396674503
Provider Name (Legal Business Name): LAKESIDE MOUNTAIN MANOR OPCO LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/14/2026
Last Update Date: 05/14/2026
Certification Date: 05/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

238 HARMONY HTS
FORSYTH MO
65653-5533
US

IV. Provider business mailing address

401 NW 10TH ST
BLUE SPRINGS MO
64015-3749
US

V. Phone/Fax

Practice location:
  • Phone: 417-546-5595
  • Fax:
Mailing address:
  • Phone: 816-815-0403
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code311Z00000X
TaxonomyCustodial Care Facility
License Number
License Number State

VIII. Authorized Official

Name: MARK HASTINGS
Title or Position: OWNER
Credential:
Phone: 417-399-3819