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General NPI Number Information
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NPI Number | 1437156171
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Entity Type | Organization
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Legal Business Name | SENIOR HEALTH-LAKESIDE, LLC
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Dates
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Enumeration Date | 07/07/2005
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Last Update Date | 08/30/2007
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Provider Practice Location Address
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Address Line | 4306 24TH ST
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City | LUBBOCK
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State | TX
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Zip | 79410-1818
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Country | US
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Telephone | 806-793-2555
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Fax | 806-793-9835
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Provider Business Mailing Address
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Address Line | 4306 24TH ST
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City | LUBBOCK
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State | TX
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Zip | 79410-1818
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Country | US
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Telephone | 806-793-2555
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Fax | 806-793-9835
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Authorized Official
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Title or Position | ADMINISTRATOR
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Name | SHANNON LYNN JANTZEN
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Credential | LNFA
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Telephone | 806-793-2555
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 314000000X
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Taxonomy Name | Skilled Nursing Facility
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License Number | 4622
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License Number State | TX
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