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General NPI Number Information
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NPI Number | 1477657823
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Entity Type | Organization
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Legal Business Name | LAKESIDE CLINIC LLC
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Dates
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Enumeration Date | 09/07/2006
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Last Update Date | 04/24/2024
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Provider Practice Location Address
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Address Line | 2337 HOMER CLAYTON DRIVE
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City | GUNTERSVILLE
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State | AL
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Zip | 35976
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Country | US
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Telephone | 256-582-5131
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Fax | 256-582-1100
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Provider Business Mailing Address
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Address Line | 2337 HOMER CLAYTON DRIVE
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City | GUNTERSVILLE
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State | AL
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Zip | 35976
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Country | US
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Telephone | 256-582-5131
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Fax | 256-582-1100
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Authorized Official
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Title or Position | ADMINISTRATOR
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Name | CAROLYN H MASON
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Credential |
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Telephone | 256-582-5131
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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