Healthcare Provider Details

I. General information

NPI: 1609171008
Provider Name (Legal Business Name): LAKESIDE LIFE RECOVERY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/14/2011
Last Update Date: 01/14/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

341 COUNTY ROAD 4874
NEWARK TX
76071-3715
US

IV. Provider business mailing address

2909 RACE ST
FORT WORTH TX
76111-4134
US

V. Phone/Fax

Practice location:
  • Phone: 817-831-4673
  • Fax:
Mailing address:
  • Phone: 817-831-4673
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State

VIII. Authorized Official

Name: MR. DON PERRY JOHNSON SR.
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 972-754-6257