=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104159144
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LAKESIDE CURATIVE SERVICES, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/09/2009
-----------------------------------------------------
Last Update Date | 09/09/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2503 LINCOLNWOOD CT
-----------------------------------------------------
City | RACINE
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53403-3869
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 262-598-8304
-----------------------------------------------------
Fax | 262-598-0083
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2503 LINCOLNWOOD CT
-----------------------------------------------------
City | RACINE
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53403-3869
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 262-598-8304
-----------------------------------------------------
Fax | 262-598-0083
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | MRS. MAGGIE LUCILLE WHITE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 262-598-8304
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251C00000X
-----------------------------------------------------
Taxonomy Name | Developmentally Disabled Services Day Training Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------