Healthcare Provider Details

I. General information

NPI: 1780990457
Provider Name (Legal Business Name): LAKESIDE HEALTHCARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/19/2010
Last Update Date: 08/19/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1010 W 5TH ST
REDFIELD SD
57469-2026
US

IV. Provider business mailing address

1010 W 5TH ST
REDFIELD SD
57469-2026
US

V. Phone/Fax

Practice location:
  • Phone: 605-472-2191
  • Fax: 605-472-2194
Mailing address:
  • Phone: 605-472-2191
  • Fax: 605-472-2194

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302F00000X
TaxonomyExclusive Provider Organization
License Number40127
License Number StateSD

VIII. Authorized Official

Name: ROSANNE A LEMMER
Title or Position: ADMINISTRATOR
Credential:
Phone: 605-472-2191