=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609055276
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LAKESIDE NEUROLOGY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/30/2007
-----------------------------------------------------
Last Update Date | 10/30/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2180 MCCULLOCH BLVD N
-----------------------------------------------------
City | LAKE HAVASU CITY
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 86403-6879
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 928-680-8282
-----------------------------------------------------
Fax | 928-680-8288
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1440
-----------------------------------------------------
City | LAKE HAVASU CITY
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 86405-1440
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 928-680-8282
-----------------------------------------------------
Fax | 928-680-8288
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. TIN T WIN
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 928-680-8282
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 28212
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------