Healthcare Provider Details

I. General information

NPI: 1841446804
Provider Name (Legal Business Name): LAKESIDE CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/11/2008
Last Update Date: 08/11/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13044 MARINE AVE
SAINT LOUIS MO
63146-2118
US

IV. Provider business mailing address

13044 MARINE AVE
SAINT LOUIS MO
63146-2118
US

V. Phone/Fax

Practice location:
  • Phone: 314-434-4535
  • Fax: 314-434-9157
Mailing address:
  • Phone: 314-434-4535
  • Fax: 314-434-9157

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code323P00000X
TaxonomyPsychiatric Residential Treatment Facility
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3245S0500X
TaxonomyChildren's Substance Abuse Rehabilitation Facility
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: RICH SWINGER
Title or Position: TREATMENT DIRECTOR
Credential:
Phone: 314-434-4535