Healthcare Provider Details

I. General information

NPI: 1508042961
Provider Name (Legal Business Name): LAKEVIEW HEALTHCARE SYSTEMS WATERFORD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/16/2008
Last Update Date: 11/24/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5310 BUENA PARK RD
WATERFORD WI
53185-2907
US

IV. Provider business mailing address

2011 RUTLAND DR
AUSTIN TX
78758-5421
US

V. Phone/Fax

Practice location:
  • Phone: 262-534-7297
  • Fax:
Mailing address:
  • Phone: 512-973-9700
  • Fax: 512-857-0504

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: MR. CHRISTOPHER SLOVER
Title or Position: CEO
Credential:
Phone: 512-973-9700