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General NPI Number Information
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NPI Number | 1396674503
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Entity Type | Organization
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Legal Business Name | LAKESIDE MOUNTAIN MANOR OPCO LLC
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Dates
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Enumeration Date | 05/14/2026
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Last Update Date | 05/14/2026
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Provider Practice Location Address
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Address Line | 238 HARMONY HTS
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City | FORSYTH
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State | MO
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Zip | 65653-5533
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Country | US
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Telephone | 417-546-5595
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Fax |
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Provider Business Mailing Address
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Address Line | 401 NW 10TH ST
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City | BLUE SPRINGS
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State | MO
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Zip | 64015-3749
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Country | US
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Telephone | 816-815-0403
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | MARK HASTINGS
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Credential |
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Telephone | 417-399-3819
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 311Z00000X
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Taxonomy Name | Custodial Care Facility
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License Number |
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License Number State |
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