Healthcare Provider Details

I. General information

NPI: 1588299168
Provider Name (Legal Business Name): LAKESIDE NEPA INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/04/2020
Last Update Date: 09/09/2026
Certification Date: 09/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125 SCRANTON POCONO HWY
SCRANTON PA
18505-2274
US

IV. Provider business mailing address

6070 N FEDERAL HWY
BOCA RATON FL
33487-3937
US

V. Phone/Fax

Practice location:
  • Phone: 570-344-5253
  • Fax:
Mailing address:
  • Phone: 570-344-5253
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateNULL

VIII. Authorized Official

Name: DUSTIN PILLONATO
Title or Position: OWNER
Credential:
Phone: 954-504-5210