Healthcare Provider Details

I. General information

NPI: 1417341280
Provider Name (Legal Business Name): LAKESIDE AUDIOLOGY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/19/2015
Last Update Date: 11/19/2021
Certification Date: 11/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

870 GOLD HILL RD STE 104
FORT MILL SC
29708-8988
US

IV. Provider business mailing address

870 GOLD HILL RD STE 104
FORT MILL SC
29708-8988
US

V. Phone/Fax

Practice location:
  • Phone: 803-620-8250
  • Fax: 803-638-6901
Mailing address:
  • Phone: 803-620-8250
  • Fax: 803-638-6901

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QH0700X
TaxonomyHearing and Speech Clinic/Center
License Number9758
License Number StateNC
# 4
Primary TaxonomyY
Taxonomy Code261QH0700X
TaxonomyHearing and Speech Clinic/Center
License Number4011
License Number StateSC

VIII. Authorized Official

Name: KIMBERLY BLOCK
Title or Position: DOCTOR OF AUDIOLOGY
Credential: AUD
Phone: 803-412-6789