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General NPI Number Information
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NPI Number | 1235315516
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Entity Type | Organization
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Legal Business Name | LAKESIDE MEDICAL WELLNESS CLINIC
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Dates
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Enumeration Date | 01/16/2008
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Last Update Date | 07/21/2022
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Provider Practice Location Address
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Address Line | 110 E DARBONNE ST STE B
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City | SULPHUR
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State | LA
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Zip | 70663-4958
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Country | US
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Telephone | 337-527-9529
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Fax | 337-527-5049
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Provider Business Mailing Address
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Address Line | 110 E DARBONNE ST STE B
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City | SULPHUR
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State | LA
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Zip | 70663-4958
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Country | US
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Telephone | 337-527-9529
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Fax | 337-527-5049
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Authorized Official
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Title or Position | OWNER
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Name | GEORGE E SMITH
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Credential | MD
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Telephone | 337-527-9529
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 305R00000X
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Taxonomy Name | Preferred Provider Organization
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License Number |
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License Number State | LA
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