Healthcare Provider Details

I. General information

NPI: 1053535617
Provider Name (Legal Business Name): LAKESIDE NURSING HOME, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/12/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1229 TRUMANSBURG ROAD
ITHACA NY
14850-1313
US

IV. Provider business mailing address

1229 TRUMANSBURG RD
ITHACA NY
14850-1313
US

V. Phone/Fax

Practice location:
  • Phone: 607-273-8072
  • Fax: 607-273-0373
Mailing address:
  • Phone: 607-273-8072
  • Fax: 607-273-0373

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number5401307N
License Number StateNY

VIII. Authorized Official

Name: MR. PATRICK M DEPTULA
Title or Position: ADMINISTRATOR
Credential:
Phone: 607-273-8072